Provider Demographics
NPI:1124210547
Name:BROUSSARD, WENDY L (OD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:L
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:138 GATEWAY ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-3706
Mailing Address - Country:US
Mailing Address - Phone:409-835-2041
Mailing Address - Fax:409-838-4518
Practice Address - Street 1:138 GATEWAY ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-3706
Practice Address - Country:US
Practice Address - Phone:409-835-2041
Practice Address - Fax:409-838-4518
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05101TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F0765Medicare UPIN