Provider Demographics
NPI:1225122310
Name:RUSSAKOFF, LEWIS M (MD)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:M
Last Name:RUSSAKOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:L.
Other - Middle Name:MARK
Other - Last Name:RUSSAKOFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:701 N BROADWAY
Mailing Address - Street 2:SLEEPY HOLLOW
Mailing Address - City:SLEEPY HOLLOW
Mailing Address - State:NY
Mailing Address - Zip Code:10591-1020
Mailing Address - Country:US
Mailing Address - Phone:914-366-3604
Mailing Address - Fax:914-366-1302
Practice Address - Street 1:701 N BROADWAY
Practice Address - Street 2:SLEEPY HOLLOW
Practice Address - City:SLEEPY HOLLOW
Practice Address - State:NY
Practice Address - Zip Code:10591-1020
Practice Address - Country:US
Practice Address - Phone:914-366-3604
Practice Address - Fax:914-366-1302
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1131982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01590647Medicaid
NY13-3297539OtherFEDERAL TAX ID NUMBER
NY01590647Medicaid
NYB13492Medicare UPIN