Provider Demographics
NPI:1326075052
Name:RUSSO, WENDY R (DC)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:R
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N CENTRE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3937
Mailing Address - Country:US
Mailing Address - Phone:516-763-2600
Mailing Address - Fax:516-763-4218
Practice Address - Street 1:100 N CENTRE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3937
Practice Address - Country:US
Practice Address - Phone:516-763-2600
Practice Address - Fax:516-763-4218
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX-007171111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU39612Medicare UPIN