Provider Demographics
NPI:1437317237
Name:ROUSE, LANCE FRANKLIN (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:FRANKLIN
Last Name:ROUSE
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:FILE 56765
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-6765
Mailing Address - Country:US
Mailing Address - Phone:602-406-3860
Mailing Address - Fax:602-406-6132
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:SUITE 710
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-406-5278
Practice Address - Fax:602-294-5665
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ445142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ626473Medicaid
AZZ146705Medicare PIN