Provider Demographics
NPI:1689840118
Name:RUSSO, FRED E (DC)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:E
Last Name:RUSSO
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 1:3689 COOLIDGE CT UNIT 7
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-7912
Mailing Address - Country:US
Mailing Address - Phone:850-422-2225
Mailing Address - Fax:850-391-4661
Practice Address - Street 1:3689 COOLIDGE CT UNIT 7
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-7912
Practice Address - Country:US
Practice Address - Phone:850-422-2225
Practice Address - Fax:850-391-4661
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006439111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22778BOtherMEDICARE PTAN
FL22778BOtherMEDICARE PTAN