Provider Demographics
NPI:1023146644
Name:RUSSO, MICHAEL ANTHONY (ND)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:RUSSO
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2636
Mailing Address - Country:US
Mailing Address - Phone:207-774-6688
Mailing Address - Fax:
Practice Address - Street 1:499 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2636
Practice Address - Country:US
Practice Address - Phone:207-774-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MENP239175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath