Provider Demographics
NPI:1003940032
Name:BROADNAX, WALTER G (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:G
Last Name:BROADNAX
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 1:1220 PADDOCK HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-1218
Mailing Address - Country:US
Mailing Address - Phone:513-421-7246
Mailing Address - Fax:513-421-7796
Practice Address - Street 1:5505 FAIR LN
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-3401
Practice Address - Country:US
Practice Address - Phone:513-421-7246
Practice Address - Fax:513-421-7796
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350606852084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0860917Medicaid
OH0681024Medicare ID - Type UnspecifiedMEDICARE
OHE96118Medicare UPIN