Provider Demographics
NPI:1740420553
Name:RUSSO, DAVID M
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:RUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 STEVEN B TANGER BLVD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-3574
Mailing Address - Country:US
Mailing Address - Phone:706-335-4630
Mailing Address - Fax:706-335-4630
Practice Address - Street 1:311 STEVEN B TANGER BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-3574
Practice Address - Country:US
Practice Address - Phone:706-335-4630
Practice Address - Fax:706-335-4630
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA520237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist