Provider Demographics
NPI:1467404251
Name:RUSSO, SANDRA L (DO)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 DEHIRSCH AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08270
Mailing Address - Country:US
Mailing Address - Phone:609-861-4241
Mailing Address - Fax:609-861-1071
Practice Address - Street 1:713 DEHIRSCH AVE
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:NJ
Practice Address - Zip Code:08270
Practice Address - Country:US
Practice Address - Phone:609-861-4241
Practice Address - Fax:609-861-1071
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06190900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7011008Medicaid
607587Medicare UPIN
NJ731353Medicare ID - Type Unspecified