Provider Demographics
NPI:1225104136
Name:BRODER, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BRODER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 TAMIAMI TRL S
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5034
Mailing Address - Country:US
Mailing Address - Phone:941-493-8878
Mailing Address - Fax:941-408-8446
Practice Address - Street 1:2165 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5034
Practice Address - Country:US
Practice Address - Phone:941-493-8878
Practice Address - Fax:941-408-8446
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2949152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6009480001Medicare NSC
FL20657Medicare ID - Type Unspecified