Provider Demographics
NPI:1710069695
Name:BROUSSARD, ANDRE EDMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:EDMOND
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1901 1ST AVE
Mailing Address - Street 2:ROOM 523
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-7404
Mailing Address - Country:US
Mailing Address - Phone:212-423-6228
Mailing Address - Fax:212-423-7697
Practice Address - Street 1:1901 FIRST AVE
Practice Address - Street 2:523
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-423-6228
Practice Address - Fax:212-534-7831
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYMD1264252080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC07074Medicare UPIN