Provider Demographics
NPI:1740718212
Name:RUSSO, DANIEL ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ALEXANDER
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 1:562 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-1816
Mailing Address - Country:US
Mailing Address - Phone:717-626-2167
Mailing Address - Fax:
Practice Address - Street 1:562 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-1816
Practice Address - Country:US
Practice Address - Phone:717-626-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT213545207Q00000X
PAMD468073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine