Doctor Name: | DR. RUSSELL JOSEPH MONGIOVI |
NPI Number: | 1104852136 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | DPM |
License Number: | N004782 |
Business Practice Address: | 3 Hemphill Pl Malta, NY - 120204419 |
Business Phone Number: | 5188993338 |
Business Fax Number: | 5188995025 |
Mailing Address: | 3 Hemphill Pl, MALTA |
State: | NY |
Postal Code: | 120204420 |
Phone Number: | 5188993338 |
Fax Number: | 5188995025 |
NPI Enumeration Date: | 06/23/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 213ES0000X |
License Number: | N004782 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NY |
Taxonomy Type: | Podiatric Medicine & Surgery Service Providers |
Taxonomy Classification: | Podiatrist |
Taxonomy Specialization: | Sports Medicine |
Taxonomy Definition: |