Basic Information
| Provider Information | |||||||||
| NPI: | 1821007170 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROUSSARD | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122309 | ||||||||
| Address2: | DEPT 2309 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753122309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942921 | ||||||||
| FaxNumber: | 3374946523 | ||||||||
| Practice Location | |||||||||
| Address1: | 2770 3RD AVE STE 350 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706010404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942750 | ||||||||
| FaxNumber: | 3374942760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 018460 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 1396826 | 05 | LA | MEDICAID | 5J895DR91 | 01 | LA | MEDICARE | OTHER |