Provider Demographics
NPI:1275612038
Name:ROUSSOS, PAMELA (DO)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
Last Name:ROUSSOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2718
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-0718
Mailing Address - Country:US
Mailing Address - Phone:209-723-0019
Mailing Address - Fax:415-946-3489
Practice Address - Street 1:1146 OLIVEWOOD DR
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-1210
Practice Address - Country:US
Practice Address - Phone:209-723-0019
Practice Address - Fax:415-946-3489
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I23813Medicare UPIN
CACM910ZMedicare PIN