Active NPI
Jerrold C Russell, OD
- Optometrist
- Columbus, WI
National Provider Identifier
1679526990
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 2029-035
- Practice address
- 1341 Park Ave
Columbus, WI 53925-1614 - Phone
- (920) 623-2431
- Fax
- (920) 623-3656
- NPI assigned
- May 18, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 2029-035 | WI | Primary |
Addresses
Primary practice location
1341 Park Ave
Columbus, WI 53925-1614
Mailing address
1341 Park Ave
Columbus, WI 53925-1614
Phone (920) 623-2431
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1679526990 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2029 | WI | MD | Registered Dietitian |
| 2029-035 | WI | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147910400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1453420800000",
"number": "1679526990",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1341 PARK AVE",
"city": "COLUMBUS",
"state": "WI",
"postal_code": "539251614",
"telephone_number": "920-623-2431",
"fax_number": "920-623-3656"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1341 PARK AVE",
"city": "COLUMBUS",
"state": "WI",
"postal_code": "539251614",
"telephone_number": "920-623-2431",
"fax_number": "920-623-3656"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RUSSELL",
"first_name": "JERROLD",
"middle_name": "C",
"credential": "OD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-18",
"last_updated": "2016-01-22",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "WI",
"license": "2029-035",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1679526990",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Columbus, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 22, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.