Healthcare Provider Details

I. General information

NPI: 1871972232
Provider Name (Legal Business Name): MICHAEL B RUSSO MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 WARD AVE SUITE #170
HONOLULU HI
96814-4015
US

IV. Provider business mailing address

8513 NE HAZEL DELL AVE SUITE #102
VANCOUVER WA
98665-8068
US

V. Phone/Fax

Practice location:
  • Phone: 808-294-3332
  • Fax:
Mailing address:
  • Phone: 360-450-3926
  • Fax: 360-450-3926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD14968
License Number StateHI

VIII. Authorized Official

Name: MICHAEL BRIAN RUSSO
Title or Position: OWNER
Credential: MD
Phone: 808-294-3332