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General NPI Number Information
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NPI Number | 1265762918
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Entity Type | Organization
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Legal Business Name | PAUL G ROUSSEAU OD PA
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Dates
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Enumeration Date | 12/31/2009
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Last Update Date | 05/03/2012
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Provider Practice Location Address
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Address Line | 5455 MURRELL RD STE 107
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City | VIERA
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State | FL
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Zip | 32955-6615
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Country | US
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Telephone | 321-636-1972
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Fax | 321-636-1507
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Provider Business Mailing Address
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Address Line | 5455 MURRELL RD STE 107
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City | VIERA
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State | FL
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Zip | 32955-6615
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Country | US
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Telephone | 321-636-1972
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Fax | 321-636-1507
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Authorized Official
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Title or Position | DEVELOPMENTAL OPTOMETRIST
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Name | DR. PAUL GERARD ROUSSEAU
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Credential | OD
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Telephone | 321-636-1972
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | OPC2641
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License Number State | FL
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