Provider Demographics
NPI:1245291277
Name:RUSSO, MELCHIORRE JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:MELCHIORRE
Middle Name:JOSEPH
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1121
Mailing Address - Country:US
Mailing Address - Phone:973-279-5116
Mailing Address - Fax:973-279-8899
Practice Address - Street 1:128 VALLEY RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1121
Practice Address - Country:US
Practice Address - Phone:973-279-5116
Practice Address - Fax:973-279-8899
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA48796173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2103907Medicaid
NJ599564Medicare ID - Type Unspecified
NJE77370Medicare UPIN