Healthcare Provider Details

I. General information

NPI: 1487282695
Provider Name (Legal Business Name): NICHOLAS ANTHONY RUSSO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ELM AND CARLTON ST
BUFFALO NY
14263
US

IV. Provider business mailing address

665 ELM ST
BUFFALO NY
14203-1104
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number329786-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number329786-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: