Provider Demographics
NPI:1184727414
Name:JAICKS, RUSSELL RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:RAYMOND
Last Name:JAICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W OAK ST
Mailing Address - Street 2:STE 101
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4989
Mailing Address - Country:US
Mailing Address - Phone:407-846-3166
Mailing Address - Fax:
Practice Address - Street 1:720 W OAK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4989
Practice Address - Country:US
Practice Address - Phone:407-846-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113621208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO28788834Medicaid
CO28788834Medicaid