Provider Demographics
NPI:1124091467
Name:ROUSSE, DARRELL A (OD)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:A
Last Name:ROUSSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 5TH ST BLDG 840
Mailing Address - Street 2:
Mailing Address - City:WRIGHT PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-7951
Mailing Address - Country:US
Mailing Address - Phone:937-938-2681
Mailing Address - Fax:
Practice Address - Street 1:2510 5TH ST BLDG 840
Practice Address - Street 2:
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-7951
Practice Address - Country:US
Practice Address - Phone:937-938-2681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2826152W00000X
OH5527152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist