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General NPI Number Information
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NPI Number | 1881335792
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Entity Type | Organization
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Legal Business Name | JOSEPH A RUSSO OD, P.C.
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Dates
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Enumeration Date | 04/05/2022
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Last Update Date | 06/29/2022
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Provider Practice Location Address
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Address Line | 364 MAINE MALL RD STE F128
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106-3206
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Country | US
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Telephone | 207-383-3456
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Fax | 207-383-3409
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Provider Business Mailing Address
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Address Line | 364 MAINE MALL RD STE F128
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106-3206
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Country | US
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Telephone | 207-383-3456
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Fax | 207-383-3409
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Authorized Official
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Title or Position | OWNER OPTOMETRIST
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Name | JOSEPH A RUSSO
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Credential | OD
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Telephone | 207-383-3456
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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