Provider Demographics
NPI:1336225994
Name:RUSSO, JOSEPH M (DPM)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014
Mailing Address - Country:US
Mailing Address - Phone:410-803-0788
Mailing Address - Fax:410-803-1859
Practice Address - Street 1:9712 BELAIR RD STE LL3
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-1110
Practice Address - Country:US
Practice Address - Phone:410-256-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01096213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD083068200Medicaid
MDE602OtherNATIONAL CAP BLUE
MDE602OtherNATIONAL CAP BLUE
MD083068200Medicaid
MDE602OtherNATIONAL CAP BLUE
MDH792OtherBLUE CROSS