Provider Demographics
NPI:1992942999
Name:Y. YOKO BROUSSARD MD, APMC
Entity type:Organization
Organization Name:Y. YOKO BROUSSARD MD, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:Y
Authorized Official - Middle Name:YOKO
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-439-2200
Mailing Address - Street 1:711 DR. MICHAEL DEBAKEY DRIVE
Mailing Address - Street 2:STE400
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601
Mailing Address - Country:US
Mailing Address - Phone:337-439-2200
Mailing Address - Fax:337-439-4484
Practice Address - Street 1:711 DR. MICHAEL DEBAKEY DRIVE
Practice Address - Street 2:STE400
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-439-2200
Practice Address - Fax:337-439-4484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022167261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1483320Medicaid
LA5A288Medicare PIN
LA1483320Medicaid