Provider Demographics
NPI:1316934326
Name:RUSSO, MARK STEVEN (MD, PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:878 109TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-1821
Mailing Address - Country:US
Mailing Address - Phone:239-513-1002
Mailing Address - Fax:239-513-1915
Practice Address - Street 1:878 109TH AVE N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-1821
Practice Address - Country:US
Practice Address - Phone:239-513-1002
Practice Address - Fax:239-513-1915
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL83306207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13594OtherBLUE CROSS BLUE SHIELD
FL263246200Medicaid
FL263246200Medicaid
FLE6954ZMedicare PIN