Individual
MARY RUSSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
400 W 16TH ST, PUEBLO, CO 81003-2745
(719) 584-4306
(719) 595-7886
Mailing address
400 W 16TH ST, PUEBLO, CO 81003-2745
(719) 584-4306
(719) 595-7886
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
5101021285
MI
207P00000X
Emergency Medicine Physician
Primary
DR.0058320
CO
390200000X
Student in an Organized Health Care Education/Training Program
5101021285
MI
Other
Enumeration date
06/10/2014
Last updated
07/21/2022
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