Provider Demographics
NPI:1902801004
Name:BROUSSARD, DWANE GERARD (MD)
Entity type:Individual
Prefix:
First Name:DWANE
Middle Name:GERARD
Last Name:BROUSSARD
Suffix:
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 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:9055 KATY FWY STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1629
Practice Address - Country:US
Practice Address - Phone:713-461-2915
Practice Address - Fax:713-461-5307
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8433K7OtherMEDICARE ID#
TX03-0494804OtherEIN #
TX8433K7OtherMEDICARE ID#