Provider Demographics
NPI:1407082522
Name:RUSSO, CLAUDE ALAN (IDMT)
Entity Type:Individual
Prefix:
First Name:CLAUDE
Middle Name:ALAN
Last Name:RUSSO
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CAPEHART RD
Mailing Address - Street 2:SGOPF
Mailing Address - City:OFFUTT A F B
Mailing Address - State:NE
Mailing Address - Zip Code:68113-1043
Mailing Address - Country:US
Mailing Address - Phone:402-294-7346
Mailing Address - Fax:402-294-9138
Practice Address - Street 1:2501 CAPEHART RD
Practice Address - Street 2:SGOPF
Practice Address - City:OFFUTT A F B
Practice Address - State:NE
Practice Address - Zip Code:68113-1043
Practice Address - Country:US
Practice Address - Phone:402-294-7346
Practice Address - Fax:402-294-9138
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians