Provider Demographics
NPI:1679528350
Name:RUSSO, PETER MARTIN (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:MARTIN
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5040
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966
Mailing Address - Country:US
Mailing Address - Phone:530-532-8584
Mailing Address - Fax:530-532-8433
Practice Address - Street 1:1611 FEATHER RIVER BLVD
Practice Address - Street 2:SUITE #10
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95965
Practice Address - Country:US
Practice Address - Phone:530-534-4530
Practice Address - Fax:530-532-8290
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39732207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00143859OtherRAILROAD MEDICARE RRM
CA00G397320Medicaid
CA00G397320Medicaid
CA00G397322Medicare ID - Type Unspecified