Healthcare Provider Details

I. General information

NPI: 1235252669
Provider Name (Legal Business Name): JOHN L ROUSSALIS M.D.PC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 STANTON CHRISTIANA RD
NEWARK DE
19713-2146
US

IV. Provider business mailing address

537 STANTON CHRISTIANA RD
NEWARK DE
19713-2146
US

V. Phone/Fax

Practice location:
  • Phone: 302-633-7550
  • Fax: 302-633-7556
Mailing address:
  • Phone: 302-633-7550
  • Fax: 302-633-7556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMD426938
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: