Basic Information
| Provider Information | |||||||||
| NPI: | 1770862971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROUSSEAU | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1912 SPEEDWAY | ||||||||
| Address2: | SUITE 546 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787121235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124955192 | ||||||||
| FaxNumber: | 8442789686 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 W 38TH ST | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787316400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123243540 | ||||||||
| FaxNumber: | 5123243541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2011 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | R0314 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2083C0008X | R0314 | TX | N |
ID Information
| ID | Type | State | Issuer | Description | 365876701 | 05 | TX | MEDICAID | 365876702 | 05 | TX | MEDICAID |