Provider Demographics
NPI:1396743506
Name:BROUSSARD, THAD STEPHENS (MD)
Entity type:Individual
Prefix:DR
First Name:THAD
Middle Name:STEPHENS
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 1:8037 PICARDY AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3538
Mailing Address - Country:US
Mailing Address - Phone:225-767-3680
Mailing Address - Fax:225-767-5578
Practice Address - Street 1:8037 PICARDY AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3538
Practice Address - Country:US
Practice Address - Phone:225-767-3680
Practice Address - Fax:225-767-5578
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014869204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1340901Medicaid
LA2695399OtherCIGNA
LA690092OtherAETNA
LA2695399OtherCIGNA
LAB61189Medicare UPIN
LA1340901Medicaid