Provider Demographics
NPI:1588661532
Name:NUSYNOWITZ, RUSSELL N (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:N
Last Name:NUSYNOWITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 ESTATES PL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-2857
Mailing Address - Country:US
Mailing Address - Phone:407-451-2069
Mailing Address - Fax:
Practice Address - Street 1:2120 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2906
Practice Address - Country:US
Practice Address - Phone:863-688-2334
Practice Address - Fax:863-577-1167
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME781902085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256418100Medicaid
FL46835OtherBCBS OF FLORIDA
FLP00042108OtherRR MEDICARE
FLF38647Medicare UPIN
FLE2474TMedicare PIN
FLP00042108OtherRR MEDICARE