Provider Demographics
NPI:1487668554
Name:RUSSO, PAUL JOHN (DO)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:JOHN
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-1541
Mailing Address - Country:US
Mailing Address - Phone:574-842-2984
Mailing Address - Fax:
Practice Address - Street 1:222 S MONTICELLO ST
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1543
Practice Address - Country:US
Practice Address - Phone:574-946-3245
Practice Address - Fax:574-946-3383
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001842A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ING60107Medicare UPIN
IN164420CMedicare ID - Type Unspecified
IN164420CMedicare PIN