Provider Demographics
NPI:1508277849
Name:LEVISTE, RUSSELL ROY SANTOS (PT)
Entity Type:Individual
Prefix:
First Name:RUSSELL ROY
Middle Name:SANTOS
Last Name:LEVISTE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27-51 27TH STREET
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102
Mailing Address - Country:US
Mailing Address - Phone:718-728-0612
Mailing Address - Fax:718-545-7771
Practice Address - Street 1:27-51 27TH STREET
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102
Practice Address - Country:US
Practice Address - Phone:718-728-0612
Practice Address - Fax:718-545-7771
Is Sole Proprietor?:No
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035003225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist