Provider Demographics
NPI:1316028376
Name:RUSSO, JACQUELINE JAUDON (MD)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:JAUDON
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5427 SW 75TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-4413
Mailing Address - Country:US
Mailing Address - Phone:352-373-0188
Mailing Address - Fax:
Practice Address - Street 1:5427 SW 75TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-4413
Practice Address - Country:US
Practice Address - Phone:352-373-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME#106414207ZP0102X
FL10064207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology