Basic Information
| Provider Information | |||||||||
| NPI: | 1316951882 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 THE DELL | ||||||||
| Address2: | |||||||||
| City: | SEARINGTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166214987 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14445 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114353109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184804024 | ||||||||
| FaxNumber: | 7184804028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 164191 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01937044 | 05 | NY | MEDICAID |