Provider Demographics
NPI:1639245798
Name:BROUSSARD, RICHARD K (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:K
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 1:439 HEYMANN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2616
Mailing Address - Country:US
Mailing Address - Phone:337-269-0963
Mailing Address - Fax:337-269-0553
Practice Address - Street 1:439 HEYMANN BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2616
Practice Address - Country:US
Practice Address - Phone:337-269-0963
Practice Address - Fax:337-269-0553
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018918207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1957356Medicaid
LA100005170OtherRAIL ROAD MEDICARE NUMBER
LA1957356Medicaid
LA256600YKF1Medicare PIN
LA1957356Medicaid