Basic Information
| Provider Information | |||||||||
| NPI: | 1942272513 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROUSSARD | ||||||||
| FirstName: | ISSAC | ||||||||
| MiddleName: | DUANE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30309 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294170309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432843400 | ||||||||
| FaxNumber: | 8432843401 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 RAWLS DR | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016840465 | ||||||||
| FaxNumber: | 6016843031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZB0001X | 12940 | MS | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZP0102X | 12940 | MS | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.