Provider Demographics
NPI:1689773574
Name:SUBIA, RUSSELL D (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:D
Last Name:SUBIA
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 1:2260 LINDA AVE
Mailing Address - Street 2:STE. 201
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-2663
Mailing Address - Country:US
Mailing Address - Phone:432-333-3937
Mailing Address - Fax:432-337-3937
Practice Address - Street 1:2260 LINDA AVE
Practice Address - Street 2:STE. 201
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-2663
Practice Address - Country:US
Practice Address - Phone:432-333-3937
Practice Address - Fax:432-337-3937
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6260 TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154996601Medicaid
TXP00027861OtherRAILROAD MEDICARE
TX134421OtherFIRSTCARE
TX0024FCOtherBLUE CROSS BLUE SHIELD
TX489485001OtherPALMETTO GBA REGION C
TX81716QOtherBCBS
TXP00027861OtherRAILROAD MEDICARE
TX154996601Medicaid