Healthcare Provider Details

I. General information

NPI: 1902369986
Provider Name (Legal Business Name): CARLOS ANDRES JAVIER RODRIGUEZ-RUSSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

516 DELAWARE ST SE
MINNEAPOLIS MN
55455-0356
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-8383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number77734
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: