Healthcare Provider Details

I. General information

NPI: 1972604189
Provider Name (Legal Business Name): GRACE NUNEZ-RUSSOTTO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 25 BELL BOULEVARD
BAYSIDE NY
11360
US

IV. Provider business mailing address

77 51 75TH STREET
GLENDALE NY
11385
US

V. Phone/Fax

Practice location:
  • Phone: 718-225-6464
  • Fax: 718-225-9316
Mailing address:
  • Phone: 718-386-5790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2024551
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: