Provider Demographics
NPI:1275891046
Name:RUSSELL, JOSHUA (MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 N BAILEY AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1206
Mailing Address - Country:US
Mailing Address - Phone:716-835-1246
Mailing Address - Fax:716-835-0396
Practice Address - Street 1:4955 N BAILEY AVE STE 130
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1206
Practice Address - Country:US
Practice Address - Phone:716-835-1246
Practice Address - Fax:716-835-0396
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY2794552084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program