Healthcare Provider Details

I. General information

NPI: 1386902401
Provider Name (Legal Business Name): RUSSELL ESMAIL PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date: 06/23/2020
Reactivation Date: 07/15/2020

III. Provider practice location address

465 GRAND ST
NEW YORK NY
10002-4800
US

IV. Provider business mailing address

349 KOSCIUSZKO ST
BROOKLYN NY
11221
US

V. Phone/Fax

Practice location:
  • Phone: 212-420-1970
  • Fax:
Mailing address:
  • Phone: 650-995-3079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: