Provider Demographics
NPI:1437126810
Name:RUSSO, ANGELO (MD)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:RUSSO
Suffix:
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 1:3939 HOUMA BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2931
Mailing Address - Country:US
Mailing Address - Phone:504-885-0577
Mailing Address - Fax:504-888-1308
Practice Address - Street 1:3939 HOUMA BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2931
Practice Address - Country:US
Practice Address - Phone:504-885-0577
Practice Address - Fax:504-888-1308
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL014788207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5120511OtherCIGNA
LA7975549OtherAETNA
LA1301370Medicaid
LA2474374OtherUNITED HEALTHCARE
4J148Medicare PIN
P00325483Medicare PIN
LA5120511OtherCIGNA