Provider Demographics
NPI:1801922851
Name:RUSSO, LEONARD MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:MICHAEL
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 1:39 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-1438
Mailing Address - Country:US
Mailing Address - Phone:973-224-5755
Mailing Address - Fax:973-227-0887
Practice Address - Street 1:186 FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-2423
Practice Address - Country:US
Practice Address - Phone:973-227-3338
Practice Address - Fax:973-227-0887
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00400500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ698-767Medicare ID - Type Unspecified
NJ689767UHFMedicare UPIN