Provider Demographics
NPI:1093726473
Name:BRODERICK, JAMES EDWARD (DPM)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 S PEARL ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424
Mailing Address - Country:US
Mailing Address - Phone:585-394-4070
Mailing Address - Fax:585-394-8563
Practice Address - Street 1:470 S PEARL ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424
Practice Address - Country:US
Practice Address - Phone:585-394-4070
Practice Address - Fax:585-394-8563
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004540213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01158323Medicaid
NY8110OtherROCHESTER BL SHIELD
NY480007845OtherRR MEDICARE
NY01158323Medicaid
T92375Medicare UPIN
NY51912BMedicare ID - Type Unspecified
51912BMedicare PIN