Provider Demographics
NPI:1770683559
Name:RUSSO, KRISTIN GALLO (OD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:GALLO
Last Name:RUSSO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MOUNT PAUL RD
Mailing Address - Street 2:
Mailing Address - City:MENDHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07945-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 SPARTA AVE.
Practice Address - Street 2:BUILDING A
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871
Practice Address - Country:US
Practice Address - Phone:973-729-5757
Practice Address - Fax:973-729-8322
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5224152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU39247Medicare UPIN
NJ484116Medicare ID - Type Unspecified