Provider Demographics
NPI:1730144064
Name:RUSSO, ROBERT J (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-886-7595
Mailing Address - Fax:858-558-8268
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-886-7595
Practice Address - Fax:858-558-8268
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62682207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG62682FMedicare ID - Type UnspecifiedGROUP# W7168
CAF05358Medicare UPIN
CA00G626820Medicaid