Provider Demographics
NPI:1477048353
Name:BROUSSARD, KENT ALLAN
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:ALLAN
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 COOLIDGE BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2636
Mailing Address - Country:US
Mailing Address - Phone:337-232-6697
Mailing Address - Fax:337-232-3147
Practice Address - Street 1:1211 COOLIDGE BLVD STE 303
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2636
Practice Address - Country:US
Practice Address - Phone:337-232-6697
Practice Address - Fax:337-232-3147
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA326325207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology