Provider Demographics
NPI:1487838660
Name:RUSSO HERRERA, LAURA TERESA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:TERESA
Last Name:RUSSO HERRERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N HALL ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-5850
Mailing Address - Country:US
Mailing Address - Phone:559-734-6701
Mailing Address - Fax:559-734-6701
Practice Address - Street 1:107 N HALL ST
Practice Address - Street 2:SUITE E
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5850
Practice Address - Country:US
Practice Address - Phone:559-734-6701
Practice Address - Fax:559-734-6701
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-23
Last Update Date:2014-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC56138207R00000X
MA234643207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine