Provider Demographics
NPI:1386447589
Name:DAMICO, RUSSELL ALAN (LDO)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALAN
Last Name:DAMICO
Suffix:
Gender:
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 W VALENCIA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-6021
Mailing Address - Country:US
Mailing Address - Phone:520-573-3264
Mailing Address - Fax:520-294-2686
Practice Address - Street 1:1650 W VALENCIA RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-6021
Practice Address - Country:US
Practice Address - Phone:520-573-3264
Practice Address - Fax:520-294-2686
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2474156FX1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric Assistant