Provider Demographics
NPI:1376006254
Name:BROUSSARD, ELZIA RENA (MD)
Entity Type:Individual
Prefix:
First Name:ELZIA
Middle Name:RENA
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 ERWIN RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4699
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:3000 ROGERS RD STE 210
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-5745
Practice Address - Country:US
Practice Address - Phone:919-385-2120
Practice Address - Fax:919-385-2144
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-00924208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics