Provider Demographics
NPI:1356301535
Name:RUSSO, PATRICIA (OD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 RUTTER AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4801
Mailing Address - Country:US
Mailing Address - Phone:570-288-7405
Mailing Address - Fax:570-288-7406
Practice Address - Street 1:703 RUTTER AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-4801
Practice Address - Country:US
Practice Address - Phone:570-288-7405
Practice Address - Fax:570-288-7406
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000855152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1434981Medicaid
PARU480432Medicare ID - Type Unspecified
PA1434981Medicaid
PA0617860003Medicare NSC