Healthcare Provider Details

I. General information

NPI: 1154681633
Provider Name (Legal Business Name): DARIC J RUSSELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3385 POTOMAC WAY
IDAHO FALLS ID
83404-4978
US

IV. Provider business mailing address

3385 POTOMAC WAY
IDAHO FALLS ID
83404-4978
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-7246
  • Fax: 208-529-2620
Mailing address:
  • Phone: 208-522-7246
  • Fax: 208-529-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number0-1036
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: