Provider Demographics
NPI:1336589704
Name:RUSSOM, ELSA (MD)
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:RUSSOM
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 1:506 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215
Mailing Address - Country:US
Mailing Address - Phone:718-780-3775
Mailing Address - Fax:718-780-3774
Practice Address - Street 1:506 6TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215
Practice Address - Country:US
Practice Address - Phone:718-780-3775
Practice Address - Fax:718-780-3774
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT524432084P0800X
NY270589-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry