Healthcare Provider Details

I. General information

NPI: 1225013196
Provider Name (Legal Business Name): JACOB DUDLEY ROUSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S ORANGE ST
NEW SMYRNA BEACH FL
32168-7320
US

IV. Provider business mailing address

603 S ORANGE ST
NEW SMYRNA BEACH FL
32168-7320
US

V. Phone/Fax

Practice location:
  • Phone: 386-423-0333
  • Fax: 386-423-0042
Mailing address:
  • Phone: 386-423-0333
  • Fax: 386-423-0042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME32999
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: