Healthcare Provider Details

I. General information

NPI: 1023033081
Provider Name (Legal Business Name): JENNEFER ALLYN RUSSO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S. TUSTIN STREET
ORANGE CA
92866
US

IV. Provider business mailing address

300 HALKET ST
PITTSBURGH PA
15213-3108
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-6373
  • Fax: 714-532-2522
Mailing address:
  • Phone: 412-641-3464
  • Fax: 412-641-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD439233
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA82067
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: