Provider Demographics
NPI:1942448659
Name:RUSSO, MARK VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINCENT
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 1:310 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-4013
Mailing Address - Country:US
Mailing Address - Phone:973-725-4836
Mailing Address - Fax:
Practice Address - Street 1:310 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:NORTH CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-4013
Practice Address - Country:US
Practice Address - Phone:973-725-4836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00235500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor