Provider Demographics
NPI:1326509977
Name:BROUSSARD, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
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 1:4119 AVENUE T 1/2 UNIT RR
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-8649
Mailing Address - Country:US
Mailing Address - Phone:786-843-7869
Mailing Address - Fax:
Practice Address - Street 1:901 HARBORSIDE DR
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550
Practice Address - Country:US
Practice Address - Phone:786-843-7869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU4750208D00000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice