Provider Demographics
NPI:1003814096
Name:BRODERICK, MICHELLE A (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:A
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2015
Mailing Address - Country:US
Mailing Address - Phone:207-729-8474
Mailing Address - Fax:207-729-8955
Practice Address - Street 1:82 MAINE ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2015
Practice Address - Country:US
Practice Address - Phone:207-729-8474
Practice Address - Fax:207-729-8955
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT767152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEU01284Medicare UPIN