MEDICARE: DR. RICHARD JON RUSSE OD

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	152W00000X	Optometrist	787	CT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	410022496	OTHER		RAILROAD MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1669546842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD JON RUSSE OD

Provider Business Mailing Address
First Line	:	PO BOX 359
Second Line	:
City	:	GRANBY
State	:	CT
Zip	:	06035-2201
Country	:	US
Telephone Number	:	860-653-3008
Fax Number	:	860-653-0359

Provider Business Practice Location Address
First Line	:	16 EAST GRANBY RD
Second Line	:
City	:	GRANBY
State	:	CT
Zip	:	06035-2201
Country	:	US
Telephone Number	:	860-653-3008
Fax Number	:	860-653-0359

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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