Provider Demographics
NPI:1073511903
Name:BROUSSARD, GERALD BALL (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:BALL
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 PECANLAND RD
Mailing Address - Street 2:SUITE E-1
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-7011
Mailing Address - Country:US
Mailing Address - Phone:318-387-2015
Mailing Address - Fax:318-387-2097
Practice Address - Street 1:1250 PECANLAND RD
Practice Address - Street 2:SUITE E-1
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-7011
Practice Address - Country:US
Practice Address - Phone:318-387-2015
Practice Address - Fax:318-387-2097
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014616207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1324159Medicaid
LA5CF76Medicare ID - Type UnspecifiedLA MEDICARE #
LA1324159Medicaid