Provider Demographics
NPI:1609946987
Name:RUSSO, ROGER A (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:285 N ROUTE 303
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CONGERS
Mailing Address - State:NY
Mailing Address - Zip Code:10920-1413
Mailing Address - Country:US
Mailing Address - Phone:845-268-5122
Mailing Address - Fax:845-268-5123
Practice Address - Street 1:285 N ROUTE 303
Practice Address - Street 2:SUITE 2
Practice Address - City:CONGERS
Practice Address - State:NY
Practice Address - Zip Code:10920-1413
Practice Address - Country:US
Practice Address - Phone:845-268-5122
Practice Address - Fax:845-268-5123
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002602-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX16271Medicare ID - Type Unspecified