Provider Demographics
NPI:1295990158
Name:BORRUSO, COURTNEY DEAN (DO)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:DEAN
Last Name:BORRUSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 LAKE AVE. SUITE 4
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004
Mailing Address - Country:US
Mailing Address - Phone:440-964-3733
Mailing Address - Fax:440-964-7069
Practice Address - Street 1:2131 LAKE AVE SUITE 4
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004
Practice Address - Country:US
Practice Address - Phone:440-964-3733
Practice Address - Fax:440-964-7069
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015061207R00000X
OH34.011500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024998940003Medicaid
PA002518014OtherHIGHMARK BCBS
PA1024998940003Medicaid