Provider Demographics
NPI:1003393539
Name:BROUSSARD, ALEXIS NOELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:NOELLE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8704 SOUTHAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2716
Mailing Address - Country:US
Mailing Address - Phone:504-481-0472
Mailing Address - Fax:
Practice Address - Street 1:280 HARBISON BLVD STE T
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-2247
Practice Address - Country:US
Practice Address - Phone:803-732-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist