Individual
JERROLD C RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
1341 PARK AVE, COLUMBUS, WI 53925-1614
(920) 623-2431
(920) 623-3656
Mailing address
1341 PARK AVE, COLUMBUS, WI 53925-1614
(920) 623-2431
(920) 623-3656
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2029-035
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1679526990
—
WI
Enumeration date
05/18/2006
Last updated
01/22/2016
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