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General NPI Number Information
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NPI Number | 1023678778
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Entity Type | Individual
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Provider Name | RUSSELL LAMAR GRAY OD
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Gender | Male
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Dates
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Enumeration Date | 06/15/2019
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 795 W OVERLAND RD
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City | MERIDIAN
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State | ID
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Zip | 83642-6556
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Country | US
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Telephone | 208-871-2936
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Fax | 208-231-8595
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Provider Business Mailing Address
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Address Line | 1521 W BLUE DOWNS ST
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City | MERIDIAN
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State | ID
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Zip | 83642-8496
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Country | US
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Telephone | 208-871-2936
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Fax | 208-231-8595
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODP-100476
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License Number State | ID
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