Basic Information
| Provider Information | |||||||||
| NPI: | 1114924693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4695 MAIN ST | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035385233 | ||||||||
| FaxNumber: | 2035385246 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 KINGS HIGHWAY CUTOFF | ||||||||
| Address2: | SUITE 1A | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068245340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038151877 | ||||||||
| FaxNumber: | 2035385246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 016805 | CT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 001168053 | 05 | CT | MEDICAID |