Healthcare Provider Details

I. General information

NPI: 1316027337
Provider Name (Legal Business Name): RUSSELL ESPOSITO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 TROY SCHENECTADY RD SUITE 102
LATHAM NY
12110-2442
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD SUITE 201
LATHAM NY
12110-2442
US

V. Phone/Fax

Practice location:
  • Phone: 518-783-3110
  • Fax: 518-782-3816
Mailing address:
  • Phone: 519-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number180794
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: