Provider Demographics
NPI:1821084351
Name:LAUDON, RUSSELL JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:JAY
Last Name:LAUDON
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 1:5910 JUNCTION BLVD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5156
Mailing Address - Country:US
Mailing Address - Phone:718-592-3200
Mailing Address - Fax:718-592-3844
Practice Address - Street 1:5910 JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5156
Practice Address - Country:US
Practice Address - Phone:718-592-3200
Practice Address - Fax:718-592-3844
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00726201Medicaid
NY25537HMedicare ID - Type Unspecified
NY00726201Medicaid