Provider Demographics
NPI:1730190489
Name:RUDASILL, DON PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:DON
Middle Name:PAUL
Last Name:RUDASILL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 NE STALLINGS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2169
Mailing Address - Country:US
Mailing Address - Phone:936-564-2020
Mailing Address - Fax:936-564-9696
Practice Address - Street 1:3915 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2169
Practice Address - Country:US
Practice Address - Phone:936-564-2020
Practice Address - Fax:936-564-9696
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2634TG152W00000X, 152WC0802X, 152WL0500X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127238701Medicaid
TX127238701Medicaid
TXT15666Medicare UPIN
TX0510420001Medicare NSC