Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | PT36494 | FL |
Y | 213ES0000X | Sports Medicine | PT36494 | FL |
NPI | 1114679859 |
---|---|
Provider Name | Fabrizio Russo |
First Address | Miami, FL 33130-1894 |
Second Address | Miami, FL 33130-1806 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2022 |
Last Update Date | 24/01/2022 |