Healthcare Provider Details

I. General information

NPI: 1588957500
Provider Name (Legal Business Name): MICHAEL B. RUSSO, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 WARD AVE STE 107
HONOLULU HI
96814-4016
US

IV. Provider business mailing address

320 WARD AVE STE 107
HONOLULU HI
96814-4016
US

V. Phone/Fax

Practice location:
  • Phone: 808-294-3332
  • Fax: 808-748-2920
Mailing address:
  • Phone: 808-294-3332
  • Fax: 808-748-2920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number14968
License Number StateHI

VIII. Authorized Official

Name: DR. MICHAEL BRIAN RUSSO
Title or Position: OWNER, DOCTOR
Credential: M.D
Phone: 301-775-8731