Provider Demographics
NPI:1972083988
Name:RUSSE, MARIAISABEL
Entity type:Individual
Prefix:
First Name:MARIAISABEL
Middle Name:
Last Name:RUSSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 CALLE CONVENTO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00912-3207
Mailing Address - Country:US
Mailing Address - Phone:787-726-1113
Mailing Address - Fax:
Practice Address - Street 1:252 CALLE CONVENTO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00912-3207
Practice Address - Country:US
Practice Address - Phone:787-726-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-19
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22320208D00000X
PR14720I390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program