Healthcare Provider Details

I. General information

NPI: 1174580682
Provider Name (Legal Business Name): TONIA BROUSSEAU DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PRUDENTIAL DR STE 713 EMERGENCY RESOURCES GROUP
JACKSONVILLE FL
32207-8209
US

IV. Provider business mailing address

PO BOX 863640
ORLANDO FL
32886-3640
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-5682
  • Fax: 904-346-0864
Mailing address:
  • Phone: 904-396-5682
  • Fax: 904-346-0864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS9193
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberOS9193
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: