Provider Demographics
NPI:1922359769
Name:RUSSO, ANTONINO
Entity Type:Individual
Prefix:
First Name:ANTONINO
Middle Name:
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 1:871 OLD ALICE RD STE 600
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8274
Mailing Address - Country:US
Mailing Address - Phone:956-541-2102
Mailing Address - Fax:
Practice Address - Street 1:871 OLD ALICE RD STE 600
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8274
Practice Address - Country:US
Practice Address - Phone:956-541-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1124782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist