Provider Demographics
NPI:1508876236
Name:RUSSO, MARTIN T JR (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:T
Last Name:RUSSO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1310 WISCONSIN AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2472
Mailing Address - Country:US
Mailing Address - Phone:616-847-5604
Mailing Address - Fax:616-846-0141
Practice Address - Street 1:1310 WISCONSIN AVE STE 103
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417
Practice Address - Country:US
Practice Address - Phone:616-846-2640
Practice Address - Fax:616-846-3110
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101014183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4094275Medicaid
MI4094275Medicaid
MI4094275Medicaid