Provider Demographics
NPI:1841262177
Name:RUSSO, MARIAN A (MD)
Entity type:Individual
Prefix:MRS
First Name:MARIAN
Middle Name:A
Last Name:RUSSO
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 1:435 WYNNEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PELHAM MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:688 WHITE PLAINS RD STE 21
Practice Address - Street 2:
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-5059
Practice Address - Country:US
Practice Address - Phone:914-725-8688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205893-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH08841Medicare UPIN
NY11U571Medicare ID - Type Unspecified