Provider Demographics
NPI:1942202130
Name:BROUILLET, GEORGE HECTOR JR (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:HECTOR
Last Name:BROUILLET
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3421 BENSON AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-1011
Mailing Address - Country:US
Mailing Address - Phone:410-644-1880
Mailing Address - Fax:410-646-3623
Practice Address - Street 1:3421 BENSON AVE
Practice Address - Street 2:STE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227-1011
Practice Address - Country:US
Practice Address - Phone:410-644-1880
Practice Address - Fax:410-646-3623
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD19096207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD118471700Medicaid
MDH726I235Medicare ID - Type Unspecified
MD118471700Medicaid