Provider Demographics
NPI:1689740607
Name:BROCCOLI, RUSSELL DAVID (DC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:DAVID
Last Name:BROCCOLI
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 1:635 HOPE STREET
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906
Mailing Address - Country:US
Mailing Address - Phone:401-351-6390
Mailing Address - Fax:401-331-0614
Practice Address - Street 1:635 HOPE STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-351-6390
Practice Address - Fax:401-331-0614
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDCP00204111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI90476OtherBCBS
RI204088OtherBLUE CHIP