Provider Demographics
NPI:1790776482
Name:BROUSSARD, JEFFREY K (MD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:K
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:501 20TH ST
Mailing Address - Street 2:SUITE 606
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1809
Mailing Address - Country:US
Mailing Address - Phone:865-546-8040
Mailing Address - Fax:
Practice Address - Street 1:501 20TH ST
Practice Address - Street 2:SUITE 606
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916
Practice Address - Country:US
Practice Address - Phone:865-546-8040
Practice Address - Fax:865-541-2787
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27390207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN100021071OtherPHP TENNCARE
TN4087786OtherBLUECARE
TN3806937Medicaid
TN4087786OtherBLUE CROSS
TNP00154870OtherTRAVELERS MEDICARE
TNP00154870OtherTRAVELERS MEDICARE
TN3806937Medicaid