Provider Demographics
NPI:1588811665
Name:JEAN ROBERT DESROULEAUX MD,PC
Entity Type:Organization
Organization Name:JEAN ROBERT DESROULEAUX MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN-ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DESROULEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-292-7443
Mailing Address - Street 1:10 GRACE LANE
Mailing Address - Street 2:
Mailing Address - City:OYSTER BAY
Mailing Address - State:NY
Mailing Address - Zip Code:11771-4020
Mailing Address - Country:US
Mailing Address - Phone:516-292-7443
Mailing Address - Fax:516-483-7847
Practice Address - Street 1:175 FULTON AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-3718
Practice Address - Country:US
Practice Address - Phone:516-292-7443
Practice Address - Fax:516-483-7847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1817442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01485318Medicaid
NY01485318Medicaid
74H731Medicare PIN
F60686Medicare UPIN
NYF60686Medicare UPIN