Provider Demographics
NPI:1619988532
Name:RUSSO, JOIE (MD)
Entity Type:Individual
Prefix:
First Name:JOIE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18034 VENTURA BLVD STE 332
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3516
Mailing Address - Country:US
Mailing Address - Phone:818-757-2345
Mailing Address - Fax:818-757-0137
Practice Address - Street 1:18034 VENTURA BLVD STE 332
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3516
Practice Address - Country:US
Practice Address - Phone:818-757-2345
Practice Address - Fax:818-757-0137
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8335207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA115297Medicare UPIN
CAW20A8335AMedicare PIN