Provider Demographics
NPI:1669784419
Name:RUSSO, MARK BRENNAN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRENNAN
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PT, DPT
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 250264
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-0264
Mailing Address - Country:US
Mailing Address - Phone:972-315-1234
Mailing Address - Fax:
Practice Address - Street 1:751 HEBRON PKWY STE 160
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-5120
Practice Address - Country:US
Practice Address - Phone:972-315-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1178901251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health