Provider Demographics
NPI:1689628216
Name:LARUSSA, LEONARD R (DPM)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:R
Last Name:LARUSSA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201A REES ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3752
Mailing Address - Country:US
Mailing Address - Phone:229-931-0505
Mailing Address - Fax:229-931-0509
Practice Address - Street 1:201A REESE STREET
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3752
Practice Address - Country:US
Practice Address - Phone:229-931-0505
Practice Address - Fax:229-931-0509
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000775213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000709574EMedicaid
GAPOD000775OtherPODIATRY LICENSE
GA3274611900OtherPECOS