Provider Demographics
NPI:1972604189
Name:NUNEZ-RUSSOTTO, GRACE (MD)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:NUNEZ-RUSSOTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 51 75TH STREET
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385
Mailing Address - Country:US
Mailing Address - Phone:718-386-5790
Mailing Address - Fax:
Practice Address - Street 1:23 25 BELL BOULEVARD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360
Practice Address - Country:US
Practice Address - Phone:718-225-6464
Practice Address - Fax:718-225-9316
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2024551208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics