Provider Demographics
NPI:1609838101
Name:THANE, TRUSSELL L
Entity Type:Individual
Prefix:
First Name:TRUSSELL
Middle Name:L
Last Name:THANE
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 1:1501 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79553-6882
Mailing Address - Country:US
Mailing Address - Phone:325-773-2083
Mailing Address - Fax:325-773-2526
Practice Address - Street 1:1501 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:TX
Practice Address - Zip Code:79553-6882
Practice Address - Country:US
Practice Address - Phone:325-773-2083
Practice Address - Fax:325-773-2526
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04720TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126535701Medicaid
TX126535701Medicaid
TX00E04TMedicare PIN
TX0871620001Medicare NSC