Individual
MICHAEL ANTHONY RUSSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1811 BROOKFURST ST #5600, FOUNTAIN VALLEY, CA 92708-6728
(714) 861-4666
(714) 861-4682
Mailing address
1811 BROOKFURST ST #5600, FOUNTAIN VALLEY, CA 92708-6728
(714) 861-4666
(714) 861-4682
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
A125016
CA
208600000X
Surgery Physician
Q1013
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
ASO2532199374
NV BOARD OF PHARM
NV
01
—
LL1802
NV MEDICAL LICENSE
NV
Enumeration date
07/05/2007
Last updated
03/07/2023
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