Healthcare Provider Details

I. General information

NPI: 1912343096
Provider Name (Legal Business Name): DOUGLAS RUSSELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3327 RESEARCH PLZ STE 403
SAN ANTONIO TX
78235
US

IV. Provider business mailing address

7909 FREDERICKSBURG RD STE 110
SAN ANTONIO TX
78229-3400
US

V. Phone/Fax

Practice location:
  • Phone: 210-337-6228
  • Fax:
Mailing address:
  • Phone: 210-614-4544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberR6890
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: