Provider Demographics
NPI:1881335792
Name:JOSEPH A RUSSO OD, P.C.
Entity type:Organization
Organization Name:JOSEPH A RUSSO OD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-383-3456
Mailing Address - Street 1:364 MAINE MALL RD STE F128
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3206
Mailing Address - Country:US
Mailing Address - Phone:207-383-3456
Mailing Address - Fax:207-383-3409
Practice Address - Street 1:364 MAINE MALL RD STE F128
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3206
Practice Address - Country:US
Practice Address - Phone:207-383-3456
Practice Address - Fax:207-383-3409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty