Provider Demographics
NPI:1417334715
Name:DOAN, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:DOAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 INTERSTATE HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-4309
Mailing Address - Country:US
Mailing Address - Phone:903-454-0100
Mailing Address - Fax:903-454-3947
Practice Address - Street 1:1118 INTERSTATE HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-4309
Practice Address - Country:US
Practice Address - Phone:903-454-0100
Practice Address - Fax:903-454-3947
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX0030800332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX011450601Medicaid
TX010050501Medicaid
TX0897540001OtherPTAN