Provider Demographics
NPI:1114026812
Name:ROUSSIS, VASILIOS (MD)
Entity Type:Individual
Prefix:
First Name:VASILIOS
Middle Name:
Last Name:ROUSSIS
Suffix:
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 1:2876 GUARDIAN LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7327
Mailing Address - Country:US
Mailing Address - Phone:757-463-5240
Mailing Address - Fax:757-463-6572
Practice Address - Street 1:1100 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2403
Practice Address - Country:US
Practice Address - Phone:757-366-3100
Practice Address - Fax:757-366-9474
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038968207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA51384OtherSENTARA
VA006021484Medicaid
VA541719389OtherTRICARE FOR LIFE
VA080138319OtherRR MEDICARE
VA541719389OtherHEALTHNET - TRICARE/CHAMP
VA150103200OtherUS DEPT OF LABOR
VA2101413OtherALLIANCE/OPTIMUM CHOICE
VA043281OtherANTHEM
VA080071877Medicare PIN
VA51384OtherSENTARA
VA2101413OtherALLIANCE/OPTIMUM CHOICE