Provider Demographics
NPI:1306847793
Name:BERDOFF, RUSSELL LINDSAY (HD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LINDSAY
Last Name:BERDOFF
Suffix:
Gender:M
Credentials:HD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 IRVING PL
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-2202
Mailing Address - Country:US
Mailing Address - Phone:212-979-9224
Mailing Address - Fax:212-674-7138
Practice Address - Street 1:67 IRVING PL
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2202
Practice Address - Country:US
Practice Address - Phone:212-979-9224
Practice Address - Fax:212-674-7138
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141351207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00824942Medicaid
NY23A273Medicare ID - Type Unspecified
NY00824942Medicaid