Provider Demographics
NPI:1417334715
Name:DOAN, RUSSELL
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:DOAN
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 1:1491 T L TOWNSEND DR STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-4907
Mailing Address - Country:US
Mailing Address - Phone:903-454-0100
Mailing Address - Fax:
Practice Address - Street 1:1491 T L TOWNSEND DR STE 101
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-4907
Practice Address - Country:US
Practice Address - Phone:903-454-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
TX0030800332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX011450601Medicaid
TX010050501Medicaid
TX0897540001OtherPTAN