Healthcare Provider Details

I. General information

NPI: 1932524154
Provider Name (Legal Business Name): AVERI DIRUSSO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DAI OK MOON MD, PA

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

C-83 OMEGA DRIVE ST FRANCIS HOSPITAL
NEWARK DE
19713-2064
US

IV. Provider business mailing address

C-83 OMEGA DRIVE ST FRANCIS HOSPITAL
NEWARK DE
19713
US

V. Phone/Fax

Practice location:
  • Phone: 302-731-0600
  • Fax:
Mailing address:
  • Phone: 302-731-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberC1-0002324
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: