Provider Demographics
NPI:1831282904
Name:RUSSO, ROBERT EDWARD
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EDWARD
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:PO BOX 35
Mailing Address - Street 2:18 RAILROAD STREET
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05453
Mailing Address - Country:US
Mailing Address - Phone:802-879-4515
Mailing Address - Fax:802-879-4515
Practice Address - Street 1:18 RAILROAD STREET
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05453
Practice Address - Country:US
Practice Address - Phone:802-879-4515
Practice Address - Fax:802-879-4515
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT14156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006615Medicaid
0162600001Medicare ID - Type Unspecified