Provider Demographics
NPI:1366634792
Name:RUSSAKOVSKY, ALEX (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:
Last Name:RUSSAKOVSKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MCGRATH HWY
Mailing Address - Street 2:# 4
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4508
Mailing Address - Country:US
Mailing Address - Phone:617-721-8880
Mailing Address - Fax:
Practice Address - Street 1:22 MCGRATH HWY
Practice Address - Street 2:PEARLE VISION
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-4508
Practice Address - Country:US
Practice Address - Phone:617-625-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist