Provider Demographics
NPI:1154681633
Name:RUSSELL, DARIC J (DO)
Entity Type:Individual
Prefix:
First Name:DARIC
Middle Name:J
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3385 POTOMAC WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4978
Mailing Address - Country:US
Mailing Address - Phone:208-522-7246
Mailing Address - Fax:208-529-2620
Practice Address - Street 1:3385 POTOMAC WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4978
Practice Address - Country:US
Practice Address - Phone:208-522-7246
Practice Address - Fax:208-529-2620
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ID0-1036207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine