Provider Demographics
NPI:1851341192
Name:RUSSO, ANMARIE J (OD)
Entity Type:Individual
Prefix:
First Name:ANMARIE
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50 STANIFORD ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2517
Mailing Address - Country:US
Mailing Address - Phone:617-367-4800
Mailing Address - Fax:617-589-3905
Practice Address - Street 1:88 ANSEL HALLET RD
Practice Address - Street 2:
Practice Address - City:WEST YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02673-2556
Practice Address - Country:US
Practice Address - Phone:508-771-4848
Practice Address - Fax:508-775-4103
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3897152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0369721Medicaid
003897OtherTUFT HEALTH PLAN
152022OtherHARVARD PILGRAM HLTH CARE
152022OtherHARVARD PILGRAM HLTH CARE
U69744Medicare UPIN