Healthcare Provider Details

I. General information

NPI: 1588661532
Provider Name (Legal Business Name): RUSSELL N NUSYNOWITZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 LAKELAND HILLS BLVD
LAKELAND FL
33805-2906
US

IV. Provider business mailing address

621 ESTATES PL
LONGWOOD FL
32779-2857
US

V. Phone/Fax

Practice location:
  • Phone: 863-688-2334
  • Fax: 863-577-1167
Mailing address:
  • Phone: 407-451-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberME78190
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME78190
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: