Provider Demographics
NPI:1528166634
Name:DOERKSEN, RUSSELL L (OD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:L
Last Name:DOERKSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:7570 W 21ST ST N
Mailing Address - Street 2:BLDG 1002
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1734
Mailing Address - Country:US
Mailing Address - Phone:316-721-3377
Mailing Address - Fax:316-721-6077
Practice Address - Street 1:7570 W 21ST ST N
Practice Address - Street 2:BLDG 1002
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1734
Practice Address - Country:US
Practice Address - Phone:316-721-3377
Practice Address - Fax:316-721-6077
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS1324152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3712OtherPREFERRED HEALTH SYSTEM
KS049837OtherBLUE CROSS/BLUE SHIELD
KS48-1185705OtherEIN #
KS410031746Medicare PIN
KS049837OtherBLUE CROSS/BLUE SHIELD
KS049837Medicare PIN
KS3712OtherPREFERRED HEALTH SYSTEM