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General NPI Number Information
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NPI Number | 1124351937
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Entity Type | Individual
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Provider Name | JAMES RUSSELL O.D.
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Gender | Male
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Dates
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Enumeration Date | 09/10/2009
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Last Update Date | 04/21/2017
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Provider Practice Location Address
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Address Line | 2478 BURNSED BLVD # 466-A
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City | THE VILLAGES
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State | FL
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Zip | 32163-2702
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Country | US
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Telephone | 352-399-5412
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Fax |
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Provider Business Mailing Address
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Address Line | 1774 WINDSORBROOKE DR
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City | MARIETTA
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State | GA
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Zip | 30062-4831
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Country | US
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Telephone |
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Fax |
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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 | OPC4461
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT2551
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License Number State | GA
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