Provider Demographics
NPI:1033466552
Name:BROADDUS, REUBEN HANCOCK JR (MD)
Entity Type:Individual
Prefix:DR
First Name:REUBEN
Middle Name:HANCOCK
Last Name:BROADDUS
Suffix:JR
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 1:511 GLENDALE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-7227
Mailing Address - Country:US
Mailing Address - Phone:804-740-1604
Mailing Address - Fax:
Practice Address - Street 1:511 GLENDALE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-7227
Practice Address - Country:US
Practice Address - Phone:804-740-1604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101013958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine