Provider Demographics
NPI:1275626566
Name:HOSSALLA, DORIS EILEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DORIS
Middle Name:EILEEN
Last Name:HOSSALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 LEANDER RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-8801
Mailing Address - Country:US
Mailing Address - Phone:512-863-7586
Mailing Address - Fax:512-863-5222
Practice Address - Street 1:1524 LEANDER RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-8801
Practice Address - Country:US
Practice Address - Phone:512-863-7586
Practice Address - Fax:512-863-5222
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9586208000000X
VT042-0012090208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1018167Medicaid
TX112091701Medicaid
TX112091701Medicaid
VT001830702Medicare PIN