Provider Demographics
NPI:1316932544
Name:RUSSO, RAFFAELA D (MD)
Entity type:Individual
Prefix:
First Name:RAFFAELA
Middle Name:D
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RAFFAELA
Other - Middle Name:D
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3993 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312
Mailing Address - Country:US
Mailing Address - Phone:718-317-6252
Mailing Address - Fax:718-317-5718
Practice Address - Street 1:3993 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312
Practice Address - Country:US
Practice Address - Phone:718-317-6252
Practice Address - Fax:718-317-5718
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144141207KI0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY97K381Medicare PIN
NYB50439Medicare UPIN