Provider Demographics
NPI:1023112596
Name:RUSSOMANNO, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RUSSOMANNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2110 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2313
Mailing Address - Country:US
Mailing Address - Phone:860-258-3480
Mailing Address - Fax:860-571-6800
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 923
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-247-1876
Practice Address - Fax:860-520-1379
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2016-02-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT031537207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00131537500Medicaid
CT00131537500Medicaid
CT00131537500Medicaid