Provider Demographics
NPI:1588688576
Name:BROUSSARD, CRYSTAL R (MD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:R
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27502 BLUE CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-3521
Mailing Address - Country:US
Mailing Address - Phone:713-304-9337
Mailing Address - Fax:
Practice Address - Street 1:3466 DISCOVERY CREEK BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-7129
Practice Address - Country:US
Practice Address - Phone:324-926-5448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8243207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173686001Medicaid
GAP00267425Medicare PIN
TX8D6083Medicare PIN
TX173686001Medicaid