Provider Demographics
NPI:1447580055
Name:NERSESOV, RUSSELL (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:NERSESOV
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2071 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566
Mailing Address - Country:US
Mailing Address - Phone:516-868-7746
Mailing Address - Fax:516-977-3002
Practice Address - Street 1:2071 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4749
Practice Address - Country:US
Practice Address - Phone:516-868-7746
Practice Address - Fax:516-977-3002
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXOO8677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor