Provider Demographics
NPI:1659684751
Name:SLAUGH, RUSSELL RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:RAY
Last Name:SLAUGH
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 1:56970 YUCCA TRL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-7910
Mailing Address - Country:US
Mailing Address - Phone:760-228-2020
Mailing Address - Fax:369-228-2020
Practice Address - Street 1:56970 YUCCA TRL
Practice Address - Street 2:SUITE 101
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7910
Practice Address - Country:US
Practice Address - Phone:760-228-2020
Practice Address - Fax:760-369-2020
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1659684751OtherNPI INDIVIDUAL
1245517804OtherGROUP NPI
FK688YMedicare PIN
1245517804OtherGROUP NPI