Provider Demographics
NPI:1871565879
Name:ROUSSEAU, DAVID VICTOR (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:VICTOR
Last Name:ROUSSEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2650 STOCKTON RD
Mailing Address - Street 2:NTC #624
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-6000
Mailing Address - Country:US
Mailing Address - Phone:619-532-8225
Mailing Address - Fax:619-524-0086
Practice Address - Street 1:2650 STOCKTON RD
Practice Address - Street 2:NTC #624
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6000
Practice Address - Country:US
Practice Address - Phone:619-532-8225
Practice Address - Fax:619-524-0086
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG12252207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW2256Medicare ID - Type Unspecified
CAA38593Medicare UPIN