Provider Demographics
NPI:1356425037
Name:RUSSO, RICHARD F (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:F
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 1:245 W AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-2254
Mailing Address - Country:US
Mailing Address - Phone:859-475-3726
Mailing Address - Fax:
Practice Address - Street 1:9400 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5752
Practice Address - Country:US
Practice Address - Phone:850-208-6130
Practice Address - Fax:850-208-6139
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL75640207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254026600Medicaid
FLG23266Medicare UPIN
FL42805YMedicare ID - Type Unspecified