Provider Demographics
NPI:1669451266
Name:MCDONALD, RUSSELL N (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:N
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 39TH ST
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-4652
Mailing Address - Country:US
Mailing Address - Phone:409-962-8509
Mailing Address - Fax:409-962-0763
Practice Address - Street 1:6000 39TH ST
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-4652
Practice Address - Country:US
Practice Address - Phone:409-962-8509
Practice Address - Fax:409-962-9763
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8705207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB24725Medicare UPIN
TX00CA32Medicare ID - Type Unspecified