Provider Demographics
NPI:1023678778
Name:GRAY, RUSSELL LAMAR (OD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LAMAR
Last Name:GRAY
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 1:1521 W BLUE DOWNS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8496
Mailing Address - Country:US
Mailing Address - Phone:208-871-2936
Mailing Address - Fax:208-231-8595
Practice Address - Street 1:795 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6556
Practice Address - Country:US
Practice Address - Phone:208-871-2936
Practice Address - Fax:208-231-8595
Is Sole Proprietor?:No
Enumeration Date:2019-06-15
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDODP-100476OtherSTATE LICENSE