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General NPI Number Information
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NPI Number | 1669479663
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Entity Type | Organization
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Legal Business Name | RUSSELL JAYNE MD LTD
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Dates
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Enumeration Date | 07/05/2005
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Last Update Date | 09/27/2018
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Provider Practice Location Address
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Address Line | 6839 W CHARLESTON BLVD
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City | LAS VEGAS
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State | NV
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Zip | 89117-1635
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Country | US
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Telephone | 702-737-7258
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Fax | 702-454-7258
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Provider Business Mailing Address
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Address Line | PO BOX 50708
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City | HENDERSON
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State | NV
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Zip | 89016-0708
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Country | US
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Telephone | 702-737-7258
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Fax | 702-454-7258
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RUSSELL PATRICK JAYNE
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Credential | MD
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Telephone | 702-737-7258
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 9106
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License Number State | NV
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