Provider Demographics
NPI:1134230501
Name:ROUSSEAU, LAURIE A (DO)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 PIERCE STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870
Mailing Address - Country:US
Mailing Address - Phone:419-557-5541
Mailing Address - Fax:419-557-5542
Practice Address - Street 1:7000 STATE ROUTE 113 E
Practice Address - Street 2:
Practice Address - City:BERLIN HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44814-9348
Practice Address - Country:US
Practice Address - Phone:419-588-2975
Practice Address - Fax:419-558-2958
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114524035Medicaid
MI0G66499-003Medicare ID - Type Unspecified
MI114524035Medicaid