Provider Demographics
NPI:1386910222
Name:SUPERFINE, RUSSELL
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:SUPERFINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21150 NE 38TH AVE APT 2006
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-4040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21150 NE 38TH AVE APT 2006
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-4040
Practice Address - Country:US
Practice Address - Phone:305-331-2822
Practice Address - Fax:305-936-0509
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0033711207R00000X
TXTM00190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254443100Medicaid
FL254443100Medicaid
FL96330Medicare PIN