Provider Demographics
NPI:1427271857
Name:ROUSSEAU, PAUL G (MS OD FCOVD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:ROUSSEAU
Suffix:
Gender:
Credentials:MS OD FCOVD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5455 MURRELL RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6615
Mailing Address - Country:US
Mailing Address - Phone:321-636-1972
Mailing Address - Fax:321-636-1507
Practice Address - Street 1:5455 MURRELL RD
Practice Address - Street 2:SUITE 107
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-6615
Practice Address - Country:US
Practice Address - Phone:321-636-1972
Practice Address - Fax:321-636-1507
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2641152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU38720Medicare UPIN