Provider Demographics
NPI:1023468733
Name:RUSSO, SAM NICHOLAS (MD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:NICHOLAS
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:S.
Other - Middle Name:NICK
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6410 FANNIN ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3000
Mailing Address - Country:US
Mailing Address - Phone:832-325-6516
Mailing Address - Fax:713-512-2248
Practice Address - Street 1:6410 FANNIN ST
Practice Address - Street 2:SUITE 500
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:832-325-6516
Practice Address - Fax:713-512-2248
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR59312084N0402X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology