Provider Demographics
NPI:1003990029
Name:BRODSKY, JEFFREY ALAN (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:BRODSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 LAKE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-3466
Mailing Address - Country:US
Mailing Address - Phone:440-997-6646
Mailing Address - Fax:440-992-4238
Practice Address - Street 1:2131 LAKE AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3466
Practice Address - Country:US
Practice Address - Phone:440-997-6646
Practice Address - Fax:440-992-4238
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4336207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
110020548OtherRAILROAD MEDICARE
OH0678646Medicaid
OH000000136131OtherANTHEM
4226821Medicare PIN
110020548OtherRAILROAD MEDICARE