Provider Demographics
NPI:1669546842
Name:RUSSE, RICHARD JON (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JON
Last Name:RUSSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06035-2201
Mailing Address - Country:US
Mailing Address - Phone:860-653-3008
Mailing Address - Fax:860-653-0359
Practice Address - Street 1:16 EAST GRANBY RD
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06035-2201
Practice Address - Country:US
Practice Address - Phone:860-653-3008
Practice Address - Fax:860-653-0359
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT787152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410022496OtherRAILROAD MEDICARE
CT004024410Medicaid
T23048Medicare UPIN
CT004024410Medicaid