Healthcare Provider Details

I. General information

NPI: 1184604183
Provider Name (Legal Business Name): DAVID P RUSSO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 10TH ST
HOOD RIVER OR
97031-1565
US

IV. Provider business mailing address

1010 10TH ST
HOOD RIVER OR
97031-1565
US

V. Phone/Fax

Practice location:
  • Phone: 541-386-9500
  • Fax: 541-386-9540
Mailing address:
  • Phone: 541-386-9500
  • Fax: 541-386-9540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number46091
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberDO26464
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: