Provider Demographics
NPI:1427152743
Name:BRASSEUR, ROOSEVELT G (MD)
Entity type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:G
Last Name:BRASSEUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4038 PAINTED PONY CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-8447
Mailing Address - Country:US
Mailing Address - Phone:505-438-6191
Mailing Address - Fax:505-438-4574
Practice Address - Street 1:4038 PAINTED PONY CIR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-8447
Practice Address - Country:US
Practice Address - Phone:505-438-6191
Practice Address - Fax:505-438-4574
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-18152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49189237Medicare UPIN