Provider Demographics
NPI:1669606422
Name:BROUSSARD, BRETT LOUIS (MD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:LOUIS
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:BANNER BOSWELL SURGICAL ONCOLOGY
Mailing Address - Street 2:13188 N. 103RD DRIVE, SUITE 200
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351
Mailing Address - Country:US
Mailing Address - Phone:623-832-3444
Mailing Address - Fax:623-832-3470
Practice Address - Street 1:BANNER BOSWELL SURGICAL ONCOLOGY
Practice Address - Street 2:13188 N. 103RD DRIVE, SUITE 200
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351
Practice Address - Country:US
Practice Address - Phone:623-832-3444
Practice Address - Fax:623-832-3470
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2020-02-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ56911208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program