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General NPI Number Information
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NPI Number | 1114955846
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Entity Type | Individual
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Provider Name | CRYSTAL N BROUSSARD MD
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Gender | Female
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Dates
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Enumeration Date | 06/29/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 466 OLD HOOK RD SUITE 1
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City | EMERSON
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State | NJ
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Zip | 07630-1396
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Country | US
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Telephone | 201-967-8221
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Fax | 201-634-9647
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Provider Business Mailing Address
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Address Line | 26 LINCOLN AVE
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City | WEST ORANGE
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State | NJ
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Zip | 07052-2312
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Country | US
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Telephone | 973-762-4466
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 69764
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License Number State | NJ
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