Provider Demographics
NPI:1184604183
Name:RUSSO, DAVID P (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1565
Mailing Address - Country:US
Mailing Address - Phone:541-386-9500
Mailing Address - Fax:541-386-9540
Practice Address - Street 1:1010 10TH ST
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1565
Practice Address - Country:US
Practice Address - Phone:541-386-9500
Practice Address - Fax:541-386-9540
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46091208100000X
ORDO264642081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
H91329Medicare UPIN
MNP00038145Medicare ID - Type UnspecifiedRAILROAD