Provider Demographics
NPI:1558329771
Name:ROSSELLO, DAVID A (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:ROSSELLO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3580 MASSEE LANE SUITE G
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909
Mailing Address - Country:US
Mailing Address - Phone:762-583-6110
Mailing Address - Fax:762-583-6101
Practice Address - Street 1:3580 MASSEE LANE SUITE G
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909
Practice Address - Country:US
Practice Address - Phone:762-583-6110
Practice Address - Fax:762-583-6101
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 002439152W00000X, 152WC0802X
GAOPT002439152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV06677Medicare UPIN