Provider Demographics
NPI:1417920117
Name:ROUSSEL, ANDY JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANDY
Middle Name:JOSEPH
Last Name:ROUSSEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 FINANCIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2460
Mailing Address - Country:US
Mailing Address - Phone:703-491-9500
Mailing Address - Fax:703-491-9994
Practice Address - Street 1:1721 FINANCIAL LOOP
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2460
Practice Address - Country:US
Practice Address - Phone:703-491-9500
Practice Address - Fax:703-491-9994
Is Sole Proprietor?:No
Enumeration Date:2006-02-12
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300955213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAV11390Medicare UPIN