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General NPI Number Information
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NPI Number | 1780650945
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Entity Type | Individual
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Provider Name | RUSSELL R GIST O.D.
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Gender | Male
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Dates
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Enumeration Date | 02/27/2006
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Last Update Date | 12/08/2022
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Provider Practice Location Address
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Address Line | 1810 SW WHITE BIRCH CIR STE 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 | SUITE #109 1810 SW WHITE BIRCH CIRCLE
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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 |
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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 | IA02183
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License Number State | IA
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