Organization
PAUL G ROUSSEAU OD PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PAUL G ROUSSEAU OD (OWNER / PRESIDENT)
(321) 636-1972
Entity
Organization
Contact information
Practice address
5455 MURRELL ROAD, SUITE 107, MELBOURNE, FL 32955-1986
(321) 636-1972
(321) 636-1507
Mailing address
5455 MURRELL ROAD, SUITE 107, MELBOURNE, FL 32955-1986
(321) 636-1972
(321) 636-1507
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OPC2641
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20396
MEDICARE PTAN
FL
Enumeration date
05/20/2009
Last updated
05/03/2012
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