Provider Demographics
NPI:1700831492
Name:RUSSELL R GIST OD PC
Entity Type:Organization
Organization Name:RUSSELL R GIST OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GIST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:515-965-8488
Mailing Address - Street 1:1810 SW WHITE BIRCH CIR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-7226
Mailing Address - Country:US
Mailing Address - Phone:515-965-8488
Mailing Address - Fax:515-965-8499
Practice Address - Street 1:1810 SW WHITE BIRCH CIR
Practice Address - Street 2:SUITE 109
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-7226
Practice Address - Country:US
Practice Address - Phone:515-965-8488
Practice Address - Fax:515-965-8499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI17757Medicare PIN