Provider Demographics
NPI:1336433655
Name:RUSSO, CHRISTIAN J (DC)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:J
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 1:4 BROOKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-4302
Mailing Address - Country:US
Mailing Address - Phone:646-210-4347
Mailing Address - Fax:718-328-7448
Practice Address - Street 1:4 BROOKSIDE RD
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-4302
Practice Address - Country:US
Practice Address - Phone:646-210-4347
Practice Address - Fax:718-328-7448
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012030111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor