Provider Demographics
NPI:1841265345
Name:DEIDIKER, RUSSELL D (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:D
Last Name:DEIDIKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:312 LOUISE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2706
Mailing Address - Country:US
Mailing Address - Phone:573-756-4581
Mailing Address - Fax:573-756-7197
Practice Address - Street 1:1212 WEBER RD
Practice Address - Street 2:SUITE 205
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3325
Practice Address - Country:US
Practice Address - Phone:573-756-4581
Practice Address - Fax:573-756-7197
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113238207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208729707Medicaid