Provider Demographics
NPI:1912343096
Name:RUSSELL, DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:RUSSELL
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 1:7909 FREDERICKSBURG RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3400
Mailing Address - Country:US
Mailing Address - Phone:210-614-4544
Mailing Address - Fax:
Practice Address - Street 1:3327 RESEARCH PLZ STE 403
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78235
Practice Address - Country:US
Practice Address - Phone:210-337-6228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6890208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty