Provider Demographics
NPI:1427023720
Name:RUSSO, ANTHONY R (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:R
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1326 E LITTLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518
Mailing Address - Country:US
Mailing Address - Phone:757-583-6338
Mailing Address - Fax:757-531-9410
Practice Address - Street 1:1326 E LITTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518
Practice Address - Country:US
Practice Address - Phone:757-583-6338
Practice Address - Fax:757-531-9410
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045049207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005619424Medicaid
VA005619424Medicaid
080002704Medicare ID - Type Unspecified