Provider Demographics
NPI:1457325110
Name:BROUSSARD, BRADLEY JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JAMES
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 1:4140 FERNCREEK DR
Mailing Address - Street 2:SUITE 801
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2563
Mailing Address - Country:US
Mailing Address - Phone:910-484-2171
Mailing Address - Fax:910-484-4568
Practice Address - Street 1:4140 FERNCREEK DR
Practice Address - Street 2:SUITE 801
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2563
Practice Address - Country:US
Practice Address - Phone:910-484-2171
Practice Address - Fax:910-484-4568
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600467207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8918801Medicaid
NC18801OtherBCBS INDIVIDUAL ID NUMBER
NC18801OtherBCBS INDIVIDUAL ID NUMBER
NCF51082Medicare UPIN