Provider Demographics
NPI:1073697637
Name:RUSSO, RANDOLPH JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:JOSEPH
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SQUADRON BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5268
Mailing Address - Country:US
Mailing Address - Phone:845-634-2225
Mailing Address - Fax:845-634-2227
Practice Address - Street 1:16 SQUADRON BLVD
Practice Address - Street 2:STE 102
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-5268
Practice Address - Country:US
Practice Address - Phone:845-634-2225
Practice Address - Fax:845-634-2227
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008265-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU60824Medicare UPIN