Provider Demographics
NPI:1285615591
Name:RUSSI, MARK B (MD)
Entity type:Individual
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First Name:MARK
Middle Name:B
Last Name:RUSSI
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Gender:M
Credentials:MD
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Mailing Address - Street 1:135 COLLEGE ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2483
Mailing Address - Country:US
Mailing Address - Phone:203-785-4197
Mailing Address - Fax:203-785-7391
Practice Address - Street 1:135 COLLEGE ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2483
Practice Address - Country:US
Practice Address - Phone:203-785-4197
Practice Address - Fax:203-785-7391
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2011-04-01
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Provider Licenses
StateLicense IDTaxonomies
CT0325962083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001325960Medicaid
CT001325960Medicaid
F36723Medicare UPIN