Provider Demographics
NPI:1104852136
Name:MONGIOVI, RUSSELL JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:JOSEPH
Last Name:MONGIOVI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HEMPHILL PL
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4420
Mailing Address - Country:US
Mailing Address - Phone:518-899-3338
Mailing Address - Fax:518-899-5025
Practice Address - Street 1:3 HEMPHILL PL
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4419
Practice Address - Country:US
Practice Address - Phone:518-899-3338
Practice Address - Fax:518-899-5025
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004782213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU19121Medicare UPIN
NY54658BMedicare ID - Type Unspecified