Provider Demographics
NPI:1548269996
Name:RUSSO, DOMINIC A (DC)
Entity type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4004
Mailing Address - Country:US
Mailing Address - Phone:330-758-9400
Mailing Address - Fax:330-726-8676
Practice Address - Street 1:1265 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4004
Practice Address - Country:US
Practice Address - Phone:330-758-9400
Practice Address - Fax:330-726-8676
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0460246Medicaid
OHRU081663Medicare ID - Type Unspecified
OH0460246Medicaid