Provider Demographics
NPI:1215261425
Name:RUSSELL, DANA S
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:S
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 N DEWITT AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0311
Mailing Address - Country:US
Mailing Address - Phone:559-299-2578
Mailing Address - Fax:559-299-1557
Practice Address - Street 1:20 N DEWITT AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0311
Practice Address - Country:US
Practice Address - Phone:559-299-2578
Practice Address - Fax:559-299-1557
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL6061156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician