Healthcare Provider Details

I. General information

NPI: 1770587636
Provider Name (Legal Business Name): TOBY D BROUSSARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 RENAISSANCE BLVD 2ND FLOOR
EDMOND OK
73013-3023
US

IV. Provider business mailing address

1800 RENAISSANCE BLVD
EDMOND OK
73013-3023
US

V. Phone/Fax

Practice location:
  • Phone: 405-359-2473
  • Fax:
Mailing address:
  • Phone: 405-359-2473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20450
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number24881
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: