Healthcare Provider Details

I. General information

NPI: 1598710857
Provider Name (Legal Business Name): DAVID ALLAN BROUSSEAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 200
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-301-6219
  • Fax: 310-301-8751
Mailing address:
  • Phone: 310-301-8708
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberG82088
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberG82088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: