Provider Demographics
NPI:1255334710
Name:KOEPSELL, DONALD JOHN (D,O,)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:JOHN
Last Name:KOEPSELL
Suffix:
Gender:M
Credentials:D,O,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2698 N GALLOWAY AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6383
Mailing Address - Country:US
Mailing Address - Phone:972-285-9394
Mailing Address - Fax:972-270-7769
Practice Address - Street 1:2698 N GALLOWAY AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6383
Practice Address - Country:US
Practice Address - Phone:972-285-9394
Practice Address - Fax:972-270-7769
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8922207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121853901Medicaid
TX121853901Medicaid