Provider Demographics
NPI:1104117688
Name:BROUSSARD, GERALD B JR (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:B
Last Name:BROUSSARD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1000
Mailing Address - Country:US
Mailing Address - Phone:800-494-8260
Mailing Address - Fax:
Practice Address - Street 1:6051 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:800-494-8260
Practice Address - Fax:859-368-0437
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2826207RA0401X, 2085R0202X
390200000X
MS249822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07124262Medicaid