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General NPI Number Information
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NPI Number | 1700831492
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Entity Type | Organization
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Legal Business Name | RUSSELL R GIST OD PC
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 11/15/2007
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Provider Practice Location Address
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Address Line | 1810 SW WHITE BIRCH CIR SUITE 109
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City | ANKENY
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State | IA
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Zip | 50023-7226
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Country | US
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Telephone | 515-965-8488
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Fax | 515-965-8499
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Provider Business Mailing Address
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Address Line | 1810 SW WHITE BIRCH CIR SUITE 109
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City | ANKENY
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State | IA
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Zip | 50023-7226
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Country | US
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Telephone | 515-965-8488
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Fax | 515-965-8499
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Authorized Official
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Title or Position | PRESIDENT
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Name | RUSSELL R GIST
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Credential | O.D.
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Telephone | 515-965-8488
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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 |
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License Number State |
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