Provider Demographics
NPI:1265580096
Name:RUSSELL, CAROL MAE (DO)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:MAE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 OLD HOOK RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1381
Mailing Address - Country:US
Mailing Address - Phone:201-666-3900
Mailing Address - Fax:201-261-0505
Practice Address - Street 1:1 BAY AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4837
Practice Address - Country:US
Practice Address - Phone:973-429-6000
Practice Address - Fax:973-429-6209
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238185207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02832057Medicaid
NYWYYPT1Medicare PIN