Provider Demographics
NPI:1376700591
Name:RUSSO, JAMES KYLE II (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:KYLE
Last Name:RUSSO
Suffix:II
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 1:120 RUE LOUIS XIV
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5739
Mailing Address - Country:US
Mailing Address - Phone:337-769-7779
Mailing Address - Fax:337-769-7788
Practice Address - Street 1:120 RUE LOUIS XIV
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5739
Practice Address - Country:US
Practice Address - Phone:337-769-7779
Practice Address - Fax:337-769-7788
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND132542085R0202X
LAMD.2061622085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1063363Medicaid
LAMD.206162OtherLOUISIANA MEDICAL LICENSE
ND81183Medicaid
LAMD.206162OtherLOUISIANA MEDICAL LICENSE
LA1063363Medicaid