Provider Demographics
NPI:1275513277
Name:ROUSTA, SEPIDEH TARA (MD)
Entity Type:Individual
Prefix:
First Name:SEPIDEH
Middle Name:TARA
Last Name:ROUSTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CORNWALL CT
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3331
Mailing Address - Country:US
Mailing Address - Phone:732-613-9191
Mailing Address - Fax:732-613-1139
Practice Address - Street 1:4 CORNWALL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3331
Practice Address - Country:US
Practice Address - Phone:732-613-9191
Practice Address - Fax:732-613-1139
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06717300207W00000X, 207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7983409Medicaid
G74806Medicare UPIN
NJ012082Medicare ID - Type Unspecified