Provider Demographics
NPI:1043272958
Name:RUSSO, MICHAEL ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7610 N STEMMONS FWY STE 600
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4228
Mailing Address - Country:US
Mailing Address - Phone:214-689-5960
Mailing Address - Fax:469-713-8084
Practice Address - Street 1:7000 W PLANO PKWY STE 110
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8467
Practice Address - Country:US
Practice Address - Phone:972-306-3767
Practice Address - Fax:972-566-8839
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL26162080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DD556OtherBCBSTX
TX166239701Medicaid
TX8DD556OtherBCBSTX
TX166239701Medicaid
TX166239701Medicaid