Provider Demographics
NPI:1992761712
Name:DOUBRAVA, RUSSELL GENE (DO)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:GENE
Last Name:DOUBRAVA
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 1:2451 S FM 51
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234
Mailing Address - Country:US
Mailing Address - Phone:940-627-0088
Mailing Address - Fax:940-627-0288
Practice Address - Street 1:2451 S FM 51
Practice Address - Street 2:SUITE 100
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234
Practice Address - Country:US
Practice Address - Phone:940-627-0088
Practice Address - Fax:940-627-0288
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1642208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176202301Medicaid
857490OtherBCBS
TX8F1038Medicare ID - Type Unspecified
857490OtherBCBS