Provider Demographics
NPI:1710977913
Name:CLEMENT, ROUSSEL (MD)
Entity Type:Individual
Prefix:
First Name:ROUSSEL
Middle Name:
Last Name:CLEMENT
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 1:6265 39TH ST
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-4614
Mailing Address - Country:US
Mailing Address - Phone:409-962-4400
Mailing Address - Fax:409-962-4412
Practice Address - Street 1:6265 39TH ST
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-4614
Practice Address - Country:US
Practice Address - Phone:409-962-4400
Practice Address - Fax:409-962-4412
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB143105Medicaid
TX155554203Medicaid
TXTXB143105Medicaid
H77950Medicare UPIN