Provider Demographics
NPI:1023011327
Name:CAVALLO, RUSSELL J (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:J
Last Name:CAVALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 S RIDGE ST
Mailing Address - Street 2:SUITE UL-1
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-2867
Mailing Address - Country:US
Mailing Address - Phone:914-708-1111
Mailing Address - Fax:
Practice Address - Street 1:90 S RIDGE ST
Practice Address - Street 2:SUITE UL-1
Practice Address - City:RYE BROOK
Practice Address - State:NY
Practice Address - Zip Code:10573-2867
Practice Address - Country:US
Practice Address - Phone:914-708-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196211207XX0005X
CT038069207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT200000890Medicare ID - Type Unspecified
NYG57544Medicare UPIN
NY80G803Medicare ID - Type Unspecified