Healthcare Provider Details

I. General information

NPI: 1669479663
Provider Name (Legal Business Name): RUSSELL JAYNE MD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6839 W CHARLESTON BLVD
LAS VEGAS NV
89117-1635
US

IV. Provider business mailing address

PO BOX 50708
HENDERSON NV
89016-0708
US

V. Phone/Fax

Practice location:
  • Phone: 702-737-7258
  • Fax: 702-454-7258
Mailing address:
  • Phone: 702-737-7258
  • Fax: 702-454-7258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number9106
License Number StateNV

VIII. Authorized Official

Name: DR. RUSSELL PATRICK JAYNE
Title or Position: PRESIDENT
Credential: MD
Phone: 702-737-7258