Provider Demographics
NPI:1811423502
Name:RUSS, DE ANTE
Entity Type:Individual
Prefix:
First Name:DE ANTE
Middle Name:
Last Name:RUSS
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 1:2149 EVERGREEN RD APT 2
Mailing Address - Street 2:
Mailing Address - City:OTTAWA HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2547
Mailing Address - Country:US
Mailing Address - Phone:330-388-7856
Mailing Address - Fax:
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:330-388-7856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.135938207P00000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program