Provider Demographics
NPI:1972739472
Name:RUSSO, GABRIEL (DC)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:GLENN
Other - Middle Name:
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:655 CASTRO ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94041-2000
Mailing Address - Country:US
Mailing Address - Phone:650-363-1156
Mailing Address - Fax:650-363-1271
Practice Address - Street 1:655 CASTRO ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94041-2000
Practice Address - Country:US
Practice Address - Phone:650-363-1156
Practice Address - Fax:650-363-1271
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19969111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor