Basic Information
| Provider Information | |||||||||
| NPI: | 1215477757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEROUSELLE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32100 TELEGRAPH RD | ||||||||
| Address2: | SUITE 185 | ||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480252452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487124266 | ||||||||
| FaxNumber: | 2487124381 | ||||||||
| Practice Location | |||||||||
| Address1: | 32100 TELEGRAPH RD | ||||||||
| Address2: | SUITE 185 | ||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480252452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487124266 | ||||||||
| FaxNumber: | 2487124381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2017 | ||||||||
| LastUpdateDate: | 03/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.