Provider Demographics
NPI:1053330621
Name:BRODZIK, LEE ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:LEE ANN
Middle Name:
Last Name:BRODZIK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 CITY AVE
Mailing Address - Street 2:SUITE 540
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1626
Mailing Address - Country:US
Mailing Address - Phone:215-871-1800
Mailing Address - Fax:215-871-1807
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:SUITE 540
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-871-1800
Practice Address - Fax:215-871-1807
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S006454E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011292600003Medicaid
PA0011292600003Medicaid