Provider Demographics
NPI:1306959390
Name:RUSSO, LORENA BISCHOFF (MD)
Entity type:Individual
Prefix:DR
First Name:LORENA
Middle Name:BISCHOFF
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LORENA
Other - Middle Name:DOUD
Other - Last Name:BISCHOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1820 41ST AVE STE C
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2516
Practice Address - Country:US
Practice Address - Phone:831-686-7611
Practice Address - Fax:831-477-2009
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AX766ZMedicare PIN
G44590Medicare UPIN