Provider Demographics
NPI:1346249364
Name:RUSSO, DANIELLE R (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:R
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2102 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NAPPANEE
Practice Address - State:IN
Practice Address - Zip Code:46550-9310
Practice Address - Country:US
Practice Address - Phone:574-862-2165
Practice Address - Fax:574-862-4112
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057584A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200283860Medicaid
IN200283860Medicaid
IN236040035OtherMEDICARE PTAN
IN000000281752OtherANTHEM BCBS #
H94723Medicare UPIN
IN139700FMedicare PIN