Provider Demographics
NPI:1518046358
Name:RUSSOLILLO, GARY EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EDWARD
Last Name:RUSSOLILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:970 FARMINGTON AVE
Mailing Address - Street 2:SUITE 21
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2139
Mailing Address - Country:US
Mailing Address - Phone:860-521-2200
Mailing Address - Fax:860-521-2605
Practice Address - Street 1:970 FARMINGTON AVE
Practice Address - Street 2:SUITE 21
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2139
Practice Address - Country:US
Practice Address - Phone:860-521-2200
Practice Address - Fax:860-521-2605
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT014345208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTA55634Medicare UPIN
MA2020149Medicare ID - Type Unspecified