Healthcare Provider Details

I. General information

NPI: 1477806214
Provider Name (Legal Business Name): MICHAEL B. RUSSO MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 WARD AVE SUITE 101
HONOLULU HI
96814-4001
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: 808-748-2920
Mailing address:
  • Phone: 360-450-3926
  • Fax: 360-450-3926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL B. RUSSO
Title or Position: OWNER
Credential: MD
Phone: 808-294-3332