1003810979 NPI number — TOBY D. BROUSSARD, M.D., APMC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003810979 NPI number — TOBY D. BROUSSARD, M.D., APMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOBY D. BROUSSARD, M.D., APMC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003810979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OPELOUSAS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70571-1206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-407-0893
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1270 ATTAKAPAS DR
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
OPELOUSAS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70570-6549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-407-0893
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BROUSSARS
Authorized Official First Name:
TOBY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
337-407-0893

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  20450 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1989592 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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