Provider Demographics
NPI:1710961420
Name:ROUSSEL, MARTIN L (DC)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:L
Last Name:ROUSSEL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-5210
Mailing Address - Country:US
Mailing Address - Phone:401-253-7475
Mailing Address - Fax:401-253-8927
Practice Address - Street 1:970 HOPE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-5210
Practice Address - Country:US
Practice Address - Phone:401-253-7475
Practice Address - Fax:401-253-8927
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDCP00188111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI204125OtherBLUE CHIP
RI44-00032OtherUNITED HEALTH CARE
RI758968OtherTUFTS
RI9043-0OtherBC/BS
RI007002777OtherMEDICARE