Provider Demographics
NPI:1245243112
Name:RUSSO-DEMARA, ELLAMARIE B (DO)
Entity Type:Individual
Prefix:DR
First Name:ELLAMARIE
Middle Name:B
Last Name:RUSSO-DEMARA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 37
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:VT
Mailing Address - Zip Code:05065
Mailing Address - Country:US
Mailing Address - Phone:609-218-9447
Mailing Address - Fax:802-728-2394
Practice Address - Street 1:220 TOM MILLER RD.
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-562-2009
Practice Address - Fax:518-561-2119
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0320000521207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVN3644Medicaid
VTVN3644Medicaid
VTVN3644Medicare ID - Type UnspecifiedMEDICARE