Provider Demographics
NPI:1578530879
Name:ROUSSELO, KENNETH ALAN (OD PC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:ROUSSELO
Suffix:
Gender:M
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 TOWNE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8910
Mailing Address - Country:US
Mailing Address - Phone:919-467-4657
Mailing Address - Fax:919-462-0199
Practice Address - Street 1:258 TOWNE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8910
Practice Address - Country:US
Practice Address - Phone:919-467-4657
Practice Address - Fax:919-462-0199
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-06
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2468538FMedicare PIN
U42453Medicare UPIN