Provider Demographics
NPI:1306822523
Name:ROUSSEAU, REGINALD (MD)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:ROUSSEAU
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 1:100 MOTOR PARKWAY
Mailing Address - Street 2:LL8
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788
Mailing Address - Country:US
Mailing Address - Phone:833-547-7463
Mailing Address - Fax:631-248-5583
Practice Address - Street 1:340 HOWELLS RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5322
Practice Address - Country:US
Practice Address - Phone:833-547-7463
Practice Address - Fax:631-248-5583
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228851207LP2900X, 208VP0000X, 208VP0014X, 207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02717366Medicaid
NY05785SMedicare ID - Type UnspecifiedGHI MEDICARE
NY02717366Medicaid
NY0973T1Medicare ID - Type UnspecifiedEMPIRE MEDICARE