Healthcare Provider Details

I. General information

NPI: 1316934326
Provider Name (Legal Business Name): MARK STEVEN RUSSO MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

878 109TH AVE N
NAPLES FL
34108-1821
US

IV. Provider business mailing address

878 109TH AVE N
NAPLES FL
34108-1821
US

V. Phone/Fax

Practice location:
  • Phone: 239-513-1002
  • Fax: 239-513-1915
Mailing address:
  • Phone: 239-513-1002
  • Fax: 239-513-1915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number83306
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: