Provider Demographics
NPI:1275551509
Name:BROUSSARD, BRAD (MD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
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 1:155 HOSPITAL DR. STE 206
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-234-3204
Mailing Address - Fax:337-234-3599
Practice Address - Street 1:155 HOSPITAL DR. STE 206
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-234-3204
Practice Address - Fax:337-234-3599
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3171207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00473770OtherRR MCR
TX8DCN 1365642 TICKETOtherBCBS
TX181131701Medicaid
TX8M1458OtherBCBS TX PROVIDER NO.
TX8L13023Medicare PIN
TX8DCN 1365642 TICKETOtherBCBS