Provider Demographics
NPI:1548354178
Name:ROUSSEL, THOMAS J (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:ROUSSEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:329 WEST 40TH STREET
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4634
Mailing Address - Country:US
Mailing Address - Phone:308-635-3911
Mailing Address - Fax:308-635-3130
Practice Address - Street 1:329 WEST 40TH STREET
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4634
Practice Address - Country:US
Practice Address - Phone:308-635-3911
Practice Address - Fax:308-635-3130
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE18259207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7796362Medicaid
WY102910000Medicaid
SD7796362Medicaid
NE277619Medicare ID - Type Unspecified