Provider Demographics
NPI:1881643245
Name:RUSSO, ROBERT A (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2728
Mailing Address - Country:US
Mailing Address - Phone:585-342-8700
Mailing Address - Fax:585-342-4159
Practice Address - Street 1:1255 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2728
Practice Address - Country:US
Practice Address - Phone:585-342-8700
Practice Address - Fax:585-342-4159
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003121-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00277586OtherRAILROAD MEDICARE
NYPO3121-2BOtherWORKERS COMPENSATION
NYP020003121OtherBLUE SHIELD
NY1499389OtherGHI
NY00622495Medicaid
NY5114559OtherAETNA
NYP010003121OtherBLUE CHOICE
NY101935EQOtherPREFERRED CARE
NY1499389OtherGHI
NYRA8225Medicare ID - Type Unspecified