MEDICARE: DR. SHAYLA DEROUSSEAU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	1275891988	TX
2	207LP3000X	Pediatric Anesthesiology Physician	1275891988	TX

General Provider Information

NPI Number	:	1275891988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAYLA DEROUSSEAU M.D.

Provider Business Mailing Address
First Line	:	PO BOX 845347
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-5347
Country	:	US
Telephone Number	:	214-645-0325
Fax Number	:

Provider Business Practice Location Address
First Line	:	5323 HARRY HINES BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-7708
Country	:	US
Telephone Number	:	214-645-0325
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2012
Last Update Date	:	10/01/2017

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