Provider Demographics
NPI:1780650945
Name:GIST, RUSSELL R (OD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:R
Last Name:GIST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SUITE #109
Mailing Address - Street 2:1810 SW WHITE BIRCH CIRCLE
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:
Practice Address - Street 1:1810 SW WHITE BIRCH CIR STE 109
Practice Address - Street 2:
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
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA02183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA09236OtherWELLMARK
IA41502OtherSPECTERA
IA204258792OtherPRINCIPAL
IA38829OtherAVESIS
IA204258792OtherCIGNA
IA204258792OtherAETNA
IA275697OtherCOVENTRY
IA5420588Medicaid
IA11588747OtherUNITED HEALTH CARE
IA240864OtherMIDLAND CHOICE
IA5159658488OtherVSP
IA53055OtherDAVIS