Provider Demographics
NPI:1528300639
Name:RUSSO, CHLOE LAN (MD)
Entity type:Individual
Prefix:
First Name:CHLOE
Middle Name:LAN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:377 ROSWELL ST NE STE 205
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:470-956-9050
Mailing Address - Fax:678-560-4339
Practice Address - Street 1:3747 ROSWELL RD STE 205
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6227
Practice Address - Country:US
Practice Address - Phone:470-956-9050
Practice Address - Fax:678-560-4339
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA76158208000000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics