Provider Demographics
NPI:1700860400
Name:RUSSO, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 GRAND AVENUE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-2197
Mailing Address - Country:US
Mailing Address - Phone:512-251-5586
Mailing Address - Fax:512-549-6260
Practice Address - Street 1:821 GRAND AVENUE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-2197
Practice Address - Country:US
Practice Address - Phone:512-251-5586
Practice Address - Fax:512-549-6260
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0039208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00B91ROtherBLUE CROSS BLUE SHIELD TX
TXG0039OtherSTATE MEDICAL LICENSE
TX115675OtherAETNA
TX115675OtherAETNA