Provider Demographics
NPI:1265762918
Name:PAUL G ROUSSEAU OD PA
Entity type:Organization
Organization Name:PAUL G ROUSSEAU OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOPMENTAL OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:321-636-1972
Mailing Address - Street 1:5455 MURRELL RD STE 107
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6615
Mailing Address - Country:US
Mailing Address - Phone:321-636-1972
Mailing Address - Fax:321-636-1507
Practice Address - Street 1:5455 MURRELL RD STE 107
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32955-6615
Practice Address - Country:US
Practice Address - Phone:321-636-1972
Practice Address - Fax:321-636-1507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2641261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20396ZOtherMEDICARE PTAN
FLU38720Medicare UPIN