Provider Demographics
NPI:1821007170
Name:BROUSSARD, ROBERT CRAIG (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:CRAIG
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:PO BOX 122309
Mailing Address - Street 2:DEPT 2309
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2309
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2770 3RD AVE STE 350
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-0404
Practice Address - Country:US
Practice Address - Phone:337-494-2750
Practice Address - Fax:337-494-2760
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018460207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1396826Medicaid
LA5J895DR91OtherMEDICARE
LA$$$$$$$$$AOtherBLUE CROSS BLUE SHIELD
LA1396826Medicaid
LA290012992OtherRAILROAD MEDICARE