Provider Demographics
NPI:1376515684
Name:RUSSO, JOHN P (CHIROPRACTOR)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:RUSSO
Suffix:
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565
Mailing Address - Country:US
Mailing Address - Phone:516-599-2593
Mailing Address - Fax:
Practice Address - Street 1:10 BROADWAY
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565
Practice Address - Country:US
Practice Address - Phone:516-599-2593
Practice Address - Fax:516-599-5046
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0039471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor