Provider Demographics
NPI:1376557355
Name:ROUSSALIS, LOUIS JOHN (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:JOHN
Last Name:ROUSSALIS
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 1:1129 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2903
Mailing Address - Country:US
Mailing Address - Phone:307-234-4585
Mailing Address - Fax:307-265-7479
Practice Address - Street 1:1129 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2903
Practice Address - Country:US
Practice Address - Phone:307-234-4585
Practice Address - Fax:307-265-7479
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1921A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY301920OtherBLUE CROSS BLUE SHIELD
WY301920OtherBLUE CROSS BLUE SHIELD
WYA72897Medicare UPIN