Provider Demographics
NPI:1609809169
Name:DESROULEAUX, JEAN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ROBERT
Last Name:DESROULEAUX
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:PO BOX 33354
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-3354
Mailing Address - Country:US
Mailing Address - Phone:800-376-5566
Mailing Address - Fax:
Practice Address - Street 1:900 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2145
Practice Address - Country:US
Practice Address - Phone:800-376-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1817442085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01485318Medicaid
NY01485318Medicaid
NYF60686Medicare UPIN