Provider Demographics
NPI:1104854033
Name:ROUSE, JOHN L III (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:ROUSE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2311
Mailing Address - Country:US
Mailing Address - Phone:910-590-0601
Mailing Address - Fax:910-592-0815
Practice Address - Street 1:403 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2311
Practice Address - Country:US
Practice Address - Phone:910-590-0601
Practice Address - Fax:910-592-0815
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00-18709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC30129OtherMEDCOST
NC4415804OtherAETNA
NC8973483Medicaid
NC73483OtherNC BLUE CROSS BLUE SHIELD
NC0138820OtherUNITED HEALTHCARE
NC8973483Medicaid
NC210054AMedicare PIN