Provider Demographics
NPI:1750490595
Name:VIRUSSO, CARL (DC)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:VIRUSSO
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 1:2500 MASSACHUSETTS AVENUE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140
Mailing Address - Country:US
Mailing Address - Phone:617-661-6225
Mailing Address - Fax:617-492-2002
Practice Address - Street 1:372 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:781-235-5200
Practice Address - Fax:781-235-1103
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2117111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1144402OtherAETNA
MAAA51163OtherHARVARD PILGRIM
MAB21198402OtherCIGNA
MA319326OtherTUFTS HEALTH PLAN
MA646901OtherUNITED HEALTH CARE
MAY36498OtherBCBS
MA319326OtherTUFTS HEALTH PLAN
MA646901OtherUNITED HEALTH CARE