Individual
DR. JON W RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
205 N STATE ST, MARENGO, IL 60152-2239
(815) 568-6508
Mailing address
205 N STATE ST, MARENGO, IL 60152-2239
(815) 568-6508
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046008174
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
046008174
—
IL
Enumeration date
01/06/2006
Last updated
07/08/2007
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