Provider Demographics
NPI:1760436935
Name:ROUSSEAU, WYATT (MD)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:
Last Name:ROUSSEAU
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8220 WALNUT HILL LN
Mailing Address - Street 2:SUITE 408
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4427
Mailing Address - Country:US
Mailing Address - Phone:214-361-9777
Mailing Address - Fax:214-891-0084
Practice Address - Street 1:8220 WALNUT HILL LN
Practice Address - Street 2:SUITE 408
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4427
Practice Address - Country:US
Practice Address - Phone:214-361-9777
Practice Address - Fax:214-891-0084
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXD6860207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB26038Medicare UPIN