Provider Demographics
NPI:1457353682
Name:BROUILLETTE, BEAU (MD)
Entity Type:Individual
Prefix:DR
First Name:BEAU
Middle Name:
Last Name:BROUILLETTE
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 1:919 HIDDEN RDG
Mailing Address - Street 2:FL 6
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2713
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:5541 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2650
Practice Address - Country:US
Practice Address - Phone:318-240-7240
Practice Address - Fax:318-240-7180
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAM.D.024120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1571091Medicaid
LA5H387Medicare PIN
LA290026YJBAMedicare UPIN
LAH18745Medicare UPIN