Provider Demographics
NPI:1265737563
Name:RUSSO, MICHAEL J (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:J
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:20301 SW ACACIA ST STE 150
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1741
Mailing Address - Country:US
Mailing Address - Phone:949-274-9551
Mailing Address - Fax:949-264-8219
Practice Address - Street 1:20301 SW ACACIA ST STE 150
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1741
Practice Address - Country:US
Practice Address - Phone:949-274-9551
Practice Address - Fax:949-264-8219
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA346352251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic