Provider Demographics
NPI:1700076643
Name:DAVID R RUSSELL OD
Entity Type:Organization
Organization Name:DAVID R RUSSELL OD
Other - Org Name:VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-789-1500
Mailing Address - Street 1:916 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-3441
Mailing Address - Country:US
Mailing Address - Phone:307-789-1500
Mailing Address - Fax:307-789-0077
Practice Address - Street 1:720 6TH ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930
Practice Address - Country:US
Practice Address - Phone:307-789-1500
Practice Address - Fax:307-789-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY293T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121954500Medicaid