Provider Demographics
NPI:1174091714
Name:RUSSO, VICTOR
Entity type:Individual
Prefix:
First Name:VICTOR
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 1:15430 COUNTY ROAD 565A # MAILBOXV
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-8242
Mailing Address - Country:US
Mailing Address - Phone:954-822-8212
Mailing Address - Fax:
Practice Address - Street 1:15430 COUNTY ROAD 565A # MAILBOXV
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-8242
Practice Address - Country:US
Practice Address - Phone:954-822-8212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver