Provider Demographics
NPI:1770502361
Name:RUSSO, GREGORY K (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:K
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 6128
Mailing Address - Street 2:ROBERT D. RUSSO, M.D. & ASSOCIATES RADIOLOGY, P.C.
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-0128
Mailing Address - Country:US
Mailing Address - Phone:203-683-4570
Mailing Address - Fax:203-926-1415
Practice Address - Street 1:2909 MAIN ST
Practice Address - Street 2:ROBERT D. RUSSO, M.D. & ASSOCIATES RADIOLOGY, P.C.
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-4960
Practice Address - Country:US
Practice Address - Phone:203-683-4570
Practice Address - Fax:203-926-1415
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-03-07
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Provider Licenses
StateLicense IDTaxonomies
CT0436212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001436212Medicaid
CT010043621OtherANTHEM BC/BS
CT010043621OtherANTHEM BC/BS