Provider Demographics
NPI:1184156762
Name:RUSSOMANNO, KRISTEN L (MD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:RUSSOMANNO
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 1:110 IRVING ST NW
Mailing Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-3017
Mailing Address - Country:US
Mailing Address - Phone:202-877-8278
Mailing Address - Fax:202-877-6292
Practice Address - Street 1:1133 21ST STREET NW
Practice Address - Street 2:BUILDING 2, 8TH FLOOR
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036
Practice Address - Country:US
Practice Address - Phone:301-951-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-01
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCMD210002405207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program