Healthcare Provider Details

I. General information

NPI: 1427793074
Provider Name (Legal Business Name): MICHAEL BROUSSARD DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13430 HOOVER CREEK BLVD # 200
CHARLOTTE NC
28273-0054
US

IV. Provider business mailing address

3812 HOLLY OAK DR UNIT 15
FAYETTEVILLE NC
28314-1291
US

V. Phone/Fax

Practice location:
  • Phone: 704-910-8380
  • Fax:
Mailing address:
  • Phone: 254-415-9869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number811
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: