Provider Demographics
NPI:1679526990
Name:RUSSELL, JERROLD C (OD)
Entity type:Individual
Prefix:
First Name:JERROLD
Middle Name:C
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1614
Mailing Address - Country:US
Mailing Address - Phone:920-623-2431
Mailing Address - Fax:920-623-3656
Practice Address - Street 1:1341 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1614
Practice Address - Country:US
Practice Address - Phone:920-623-2431
Practice Address - Fax:920-623-3656
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2029-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679526990Medicaid
WI410044529Medicare PIN
WIK400176695Medicare PIN
WI000247810Medicare PIN
WI1271OtherDEAN HEALTH INSURANCE
WI38526700Medicaid