Basic Information
| Provider Information | |||||||||
| NPI: | 1114955846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROUSSARD | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | WEST ORANGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070522312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737624466 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 466 OLD HOOK RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | EMERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076301396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019678221 | ||||||||
| FaxNumber: | 2016349647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 69764 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.