Provider Demographics
NPI:1194856583
Name:DERHAK, RUSSELL S (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:S
Last Name:DERHAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 97TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-4027
Mailing Address - Country:US
Mailing Address - Phone:763-486-3945
Mailing Address - Fax:763-425-2417
Practice Address - Street 1:4630 97TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-4027
Practice Address - Country:US
Practice Address - Phone:763-486-3945
Practice Address - Fax:763-425-2417
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4717111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor