Provider Demographics
NPI:1679992036
Name:WEG, RUSSELL
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:WEG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7136 110TH ST STE 1G
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4852
Mailing Address - Country:US
Mailing Address - Phone:718-520-2210
Mailing Address - Fax:718-520-4448
Practice Address - Street 1:7136 110TH ST STE 1G
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4852
Practice Address - Country:US
Practice Address - Phone:718-520-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291260-1207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology