Healthcare Provider Details

I. General information

NPI: 1881077030
Provider Name (Legal Business Name): CARL-PHILIPPE ROUSSEAU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 E MISSISSIPPI AVE STE 110
GLENDALE CO
80246-3051
US

IV. Provider business mailing address

4100 E MISSISSIPPI AVE STE 110
GLENDALE CO
80246-3051
US

V. Phone/Fax

Practice location:
  • Phone: 303-552-9522
  • Fax: 415-252-7176
Mailing address:
  • Phone: 303-552-9522
  • Fax: 415-252-7176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number289925
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberDR.0075292
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: