Provider Demographics
NPI:1619168317
Name:ROUSSEAU, MARCELLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:MARCELLE
Middle Name:MARIE
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 PERDIDO ST
Mailing Address - Street 2:MEDICAL HOME CLINIC
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-1352
Mailing Address - Country:US
Mailing Address - Phone:504-903-3000
Mailing Address - Fax:504-903-5157
Practice Address - Street 1:2021 PERDIDO ST
Practice Address - Street 2:MEDICAL HOME CLINIC
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-1352
Practice Address - Country:US
Practice Address - Phone:504-903-3000
Practice Address - Fax:504-903-5157
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200431208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1-07388-1Medicaid