Provider Demographics
NPI:1346201811
Name:RUSSO, GILBERTO C (MD)
Entity Type:Individual
Prefix:
First Name:GILBERTO
Middle Name:C
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71777 SAN JACINTO DR
Mailing Address - Street 2:SUITE 101G
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4457
Mailing Address - Country:US
Mailing Address - Phone:760-969-6559
Mailing Address - Fax:
Practice Address - Street 1:71777 SAN JACINTO DR
Practice Address - Street 2:STE 101G
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4457
Practice Address - Country:US
Practice Address - Phone:760-969-6559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA634212086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A634213Medicare PIN
ALI17722Medicare UPIN
CA00A634212Medicare PIN
CA00A634214Medicare PIN
CA00A634211Medicare PIN
CA00A634215Medicare PIN