Provider Demographics
NPI:1053328641
Name:BRODIE, IAN DALLAS (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:DALLAS
Last Name:BRODIE
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 1:911 ELECTRIC AVE
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740
Mailing Address - Country:US
Mailing Address - Phone:562-594-8635
Mailing Address - Fax:
Practice Address - Street 1:911 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740
Practice Address - Country:US
Practice Address - Phone:562-594-8635
Practice Address - Fax:562-594-6009
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29773207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29773OtherSTATE LICENSE
A84001Medicare UPIN
A29773Medicare ID - Type Unspecified