Provider Demographics
NPI:1770795049
Name:ROUSSEAU, TERENCE A (DO)
Entity type:Individual
Prefix:DR
First Name:TERENCE
Middle Name:A
Last Name:ROUSSEAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 ZUNI ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-0920
Mailing Address - Country:US
Mailing Address - Phone:602-571-3976
Mailing Address - Fax:
Practice Address - Street 1:1231 ZUNI ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-0920
Practice Address - Country:US
Practice Address - Phone:602-571-3976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4554207Q00000X
NMA-1784-13207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine