Provider Demographics
NPI:1720047574
Name:ROUSE, DAVID WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
Last Name:ROUSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15908 WEST STATE ROAD 84
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1233
Mailing Address - Country:US
Mailing Address - Phone:954-384-6200
Mailing Address - Fax:954-384-0506
Practice Address - Street 1:15916 W STATE ROAD 84
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33326-1226
Practice Address - Country:US
Practice Address - Phone:954-384-6200
Practice Address - Fax:954-384-0506
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC2683152W00000X
FLOP2683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086891400Medicaid
FL086891400Medicaid
FLU35069Medicare UPIN