Provider Demographics
NPI:1174839161
Name:BROUSSARD, JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 2ND AVE NE STE 1401
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3480
Mailing Address - Country:US
Mailing Address - Phone:727-258-7224
Mailing Address - Fax:
Practice Address - Street 1:111 2ND AVE NE STE 1401
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3480
Practice Address - Country:US
Practice Address - Phone:727-258-7224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12241207QS0010X
VA0102204383207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine