Healthcare Provider Details

I. General information

NPI: 1821103029
Provider Name (Legal Business Name): RUSSELL E CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 10/28/2023
Certification Date: 10/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1093 DELAWARE AVE APT 5
BUFFALO NY
14209-1655
US

IV. Provider business mailing address

PO BOX 7
BUFFALO NY
14207-0007
US

V. Phone/Fax

Practice location:
  • Phone: 716-462-4415
  • Fax: 716-303-7008
Mailing address:
  • Phone: 716-462-4415
  • Fax: 716-303-7008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number189175
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: