Provider Demographics
NPI:1013913318
Name:IDEN, DONALD L (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:L
Last Name:IDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DON
Other - Middle Name:
Other - Last Name:IDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4521 S STAPLES ST
Mailing Address - Street 2:STE 100
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2603
Mailing Address - Country:US
Mailing Address - Phone:361-993-9363
Mailing Address - Fax:361-993-9366
Practice Address - Street 1:4521 S STAPLES ST
Practice Address - Street 2:STE 100
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2603
Practice Address - Country:US
Practice Address - Phone:361-993-9363
Practice Address - Fax:361-993-9366
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE 6811174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBS # K40VOtherBLUE CROSS IDENTIFIER
B23684Medicare UPIN