Provider Demographics
NPI:1386070936
Name:RUSS, EDUARDO CLEAVON (CSFA)
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:CLEAVON
Last Name:RUSS
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18002 RICHMOND PLACE DR
Mailing Address - Street 2:APT# 2425
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1724
Mailing Address - Country:US
Mailing Address - Phone:813-748-9474
Mailing Address - Fax:
Practice Address - Street 1:18002 RICHMOND PLACE DR
Practice Address - Street 2:APT# 2425
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-1724
Practice Address - Country:US
Practice Address - Phone:813-748-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-15
Last Update Date:2013-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL134686246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant