Provider Demographics
NPI:1942264189
Name:RUSSO, CHARLES LANCE (DPM)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LANCE
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 BENSON AVE
Mailing Address - Street 2:APT 4K
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214
Mailing Address - Country:US
Mailing Address - Phone:917-518-3878
Mailing Address - Fax:
Practice Address - Street 1:481 ST MARKS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238
Practice Address - Country:US
Practice Address - Phone:718-638-8185
Practice Address - Fax:718-399-2354
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003120213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00656079Medicaid
NYP34341Medicare ID - Type Unspecified
NY00656079Medicaid