Healthcare Provider Details

I. General information

NPI: 1740070127
Provider Name (Legal Business Name): KYLE STEPHEN ANG RUSSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 MAIN ST
FLUSHING NY
11355-5045
US

IV. Provider business mailing address

16147 MISSION GLEN DR
HOUSTON TX
77083-5381
US

V. Phone/Fax

Practice location:
  • Phone: 718-670-2000
  • Fax:
Mailing address:
  • Phone: 832-492-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: