Provider Demographics
NPI:1588647143
Name:RUSSO, DAVID P (MD, FACS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 POLK LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-5905
Mailing Address - Country:US
Mailing Address - Phone:800-761-7575
Mailing Address - Fax:
Practice Address - Street 1:133 POLK LN
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-5905
Practice Address - Country:US
Practice Address - Phone:800-761-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05056300207RA0401X, 208600000X, 208600000X
PAMD043941L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8285306Medicaid
NJ8285306Medicaid
PA672972TUHMedicare PIN
PAE89555Medicare UPIN
NJ423381WXTMedicare PIN
PA0012430300004Medicaid