Active NPI
Mariela Perez Russo, MD, CNS
- Nutritionist
- Trumbull, CT
National Provider Identifier
1811474612
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Nutritionist
- Practice address
- 290 Booth Hill Rd
Trumbull, CT 06611-4943 - Phone
- (646) 255-9510
- NPI assigned
- Jul 24, 2018
- Last updated
- Jul 24, 2018
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nutritionist | 133N00000X | 1644 | CT | |
| Nutritionist | 133N00000X | NU | Primary |
Addresses
Primary practice location
290 Booth Hill Rd
Trumbull, CT 06611-4943
Mailing address
290 Booth Hill Rd
Trumbull, CT 06611-4943
Phone (646) 255-9510
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Certified Nurse Specialist, Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1644 | CT | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1532390400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1532390400000",
"number": "1811474612",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "290 BOOTH HILL RD",
"city": "TRUMBULL",
"state": "CT",
"postal_code": "066114943",
"telephone_number": "646-255-9510"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "290 BOOTH HILL RD",
"city": "TRUMBULL",
"state": "CT",
"postal_code": "066114943",
"telephone_number": "646-255-9510"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PEREZ RUSSO",
"first_name": "MARIELA",
"credential": "MD, CNS",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2018-07-24",
"last_updated": "2018-07-24",
"status": "A"
},
"taxonomies": [
{
"code": "133N00000X",
"taxonomy_group": "",
"desc": "Nutritionist",
"state": "CT",
"license": "1644",
"primary": false
},
{
"code": "133N00000X",
"taxonomy_group": "",
"desc": "Nutritionist",
"state": "NU",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Trumbull, CT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 24, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.