Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 038069 | CT |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 196211 | NY |
NPI | 1023011327 |
---|---|
Provider Name | Dr. Russell J Cavallo |
First Address | Rye Brook, NY 10573-2867 |
Second Address | Rye Brook, NY 10573-2867 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2005 |
Last Update Date | 04/10/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G57544 | (02) | NY |