Provider Demographics
NPI:1316951882
Name:RUSSO, DANIEL JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 THE DELL
Mailing Address - Street 2:
Mailing Address - City:SEARINGTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11507
Mailing Address - Country:US
Mailing Address - Phone:516-621-4987
Mailing Address - Fax:
Practice Address - Street 1:14445 87TH AVE
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-3109
Practice Address - Country:US
Practice Address - Phone:718-480-4024
Practice Address - Fax:718-480-4028
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164191207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01937044Medicaid
NYG400007362Medicare PIN
NY315AH1Medicare ID - Type UnspecifiedBROOKLYN
NY01937044Medicaid