Provider Demographics
NPI:1891779013
Name:BROUILLETTE, CHRIS J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:J
Last Name:BROUILLETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 OUTER RD STE A
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6605
Mailing Address - Country:US
Mailing Address - Phone:407-895-4737
Mailing Address - Fax:321-203-4610
Practice Address - Street 1:891 OUTER RD STE A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6605
Practice Address - Country:US
Practice Address - Phone:407-895-4737
Practice Address - Fax:321-203-4610
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7627094OtherAETNA
FL7627094OtherAETNA
49377VMedicare PIN
FLH09426Medicare UPIN