Provider Demographics
NPI:1235252669
Name:ROUSSALIS, JOHN L (MDPC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:ROUSSALIS
Suffix:
Gender:M
Credentials:MDPC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:537 STANTON CHRISTIANA RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2146
Mailing Address - Country:US
Mailing Address - Phone:302-633-7550
Mailing Address - Fax:302-633-7556
Practice Address - Street 1:537 STANTON CHRISTIANA RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2146
Practice Address - Country:US
Practice Address - Phone:302-633-7550
Practice Address - Fax:302-633-7556
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4269382086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY127068100Medicaid
WYW21591OtherPTAN