Provider Demographics
NPI:1992898894
Name:RUSSELL, DAVID RAY (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RAY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 6TH ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-3702
Mailing Address - Country:US
Mailing Address - Phone:307-789-1500
Mailing Address - Fax:307-789-0077
Practice Address - Street 1:720 6TH ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930
Practice Address - Country:US
Practice Address - Phone:307-789-1500
Practice Address - Fax:307-789-0077
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY293T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1219545 00Medicaid
WY1219545 00Medicaid