Provider Demographics
NPI:1326103763
Name:ROUSSEAU, PAMELA A (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:A
Last Name:ROUSSEAU
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 1:8035 W OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-1116
Mailing Address - Country:US
Mailing Address - Phone:954-748-9196
Mailing Address - Fax:954-748-6837
Practice Address - Street 1:8035 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-1116
Practice Address - Country:US
Practice Address - Phone:954-748-9196
Practice Address - Fax:954-748-6837
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34993207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL93909Medicare ID - Type UnspecifiedPROVIDER NUMBER
FLD63051Medicare UPIN