Basic Information
| Provider Information | |||||||||
| NPI: | 1841265345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEIDIKER | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 LOUISE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636402706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737564581 | ||||||||
| FaxNumber: | 5737567197 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 WEBER RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636403325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737564581 | ||||||||
| FaxNumber: | 5737567197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 113238 | MO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 208729707 | 05 | MO | MEDICAID |