Healthcare Provider Details

I. General information

NPI: 1417984295
Provider Name (Legal Business Name): ANDREW RUSSO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 77TH ST
BROOKLYN NY
11209-3205
US

IV. Provider business mailing address

433 77TH ST
BROOKLYN NY
11209-3205
US

V. Phone/Fax

Practice location:
  • Phone: 718-238-1155
  • Fax:
Mailing address:
  • Phone: 718-238-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number224966
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: