MEDICARE: GORDON J RUSSO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207NS0135X	Procedural Dermatology Physician	015208	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083612469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GORDON J RUSSO MD

Provider Business Mailing Address
First Line	:	3725 LAKE MICHAEL CT
Second Line	:
City	:	GRETNA
State	:	LA
Zip	:	70056-8326
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 MEADOWCREST ST
Second Line	:	SUITE 160
City	:	GRETNA
State	:	LA
Zip	:	70056-5255
Country	:	US
Telephone Number	:	504-391-7620
Fax Number	:	504-391-7524

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	02/03/2010

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