Provider Demographics
NPI:1164469144
Name:BROOMALL, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:BROOMALL
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 1:4685 FOREST AVE
Mailing Address - Street 2:STE C
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8240 NORTHCREEK DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2377
Practice Address - Country:US
Practice Address - Phone:513-246-7000
Practice Address - Fax:513-246-5284
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048860207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0836251Medicaid
OHA15855Medicare UPIN
OH0836251Medicaid