Healthcare Provider Details

I. General information

NPI: 1245243351
Provider Name (Legal Business Name): THAINA ROUSSEAU-PIERRE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 BROADWAY ROOM A1-9
ELMHURST NY
11373-1329
US

IV. Provider business mailing address

7901 BROADWAY ROOM A1-9
ELMHURST NY
11373-1329
US

V. Phone/Fax

Practice location:
  • Phone: 718-334-4952
  • Fax: 718-334-4815
Mailing address:
  • Phone: 718-334-4952
  • Fax: 718-334-4815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number227115
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02791651
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: