Healthcare Provider Details

I. General information

NPI: 1043272958
Provider Name (Legal Business Name): MICHAEL ANTHONY RUSSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 W PLANO PKWY STE 110
PLANO TX
75093-8467
US

IV. Provider business mailing address

7610 N STEMMONS FWY STE 600
DALLAS TX
75247-4228
US

V. Phone/Fax

Practice location:
  • Phone: 972-306-3767
  • Fax: 972-566-8839
Mailing address:
  • Phone: 214-689-5960
  • Fax: 469-713-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberL2616
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: