Provider Demographics
NPI:1700084381
Name:RUSSO, MICHAEL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
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 1:1811 BROOKFURST ST #5600
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6728
Mailing Address - Country:US
Mailing Address - Phone:714-861-4666
Mailing Address - Fax:714-861-4682
Practice Address - Street 1:1811 BROOKFURST ST #5600
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-861-4666
Practice Address - Fax:714-861-4682
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ1013208600000X
CAA125016208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVASO2532199374OtherNV BOARD OF PHARM
NVLL1802OtherNV MEDICAL LICENSE
ASO2532199374OtherDEA