Individual
DR. BLAINE MARK BROUSSARD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
176 VERSAILLES BLVD, ALEXANDRIA, LA 71303-2493
(318) 445-9331
(318) 619-6899
Mailing address
PO BOX 13030, ALEXANDRIA, LA 71315-3030
(318) 445-9331
(318) 619-6899
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
206014
LA
208000000X
Pediatrics Physician
206014
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2339605
—
LA
Enumeration date
04/13/2009
Last updated
05/24/2022
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