Provider Demographics
NPI:1922077171
Name:RUSONIS, PAUL ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ANDREW
Last Name:RUSONIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6021 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE 390
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6077
Mailing Address - Country:US
Mailing Address - Phone:410-203-0607
Mailing Address - Fax:410-203-0677
Practice Address - Street 1:6021 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 390
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6077
Practice Address - Country:US
Practice Address - Phone:410-203-0607
Practice Address - Fax:410-203-0677
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-10-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0030058207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB67187Medicare UPIN
MD553M860FMedicare PIN