MEDICARE: DR. GERALD BALL BROUSSARD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	014616	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073511903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERALD BALL BROUSSARD MD

Provider Business Mailing Address
First Line	:	1250 PECANLAND RD
Second Line	:	SUITE E-1
City	:	MONROE
State	:	LA
Zip	:	71203-7011
Country	:	US
Telephone Number	:	318-387-2015
Fax Number	:	318-387-2097

Provider Business Practice Location Address
First Line	:	1250 PECANLAND RD
Second Line	:	SUITE E-1
City	:	MONROE
State	:	LA
Zip	:	71203-7011
Country	:	US
Telephone Number	:	318-387-2015
Fax Number	:	318-387-2097

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	07/09/2007

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