Healthcare Provider Details

I. General information

NPI: 1174839161
Provider Name (Legal Business Name): JOHN BROUSSARD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 2ND AVE NE STE 1401
ST PETERSBURG FL
33701-3480
US

IV. Provider business mailing address

111 2ND AVE NE STE 1401
ST PETERSBURG FL
33701-3480
US

V. Phone/Fax

Practice location:
  • Phone: 727-258-7224
  • Fax:
Mailing address:
  • Phone: 727-258-7224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS12241
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0102204383
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: