Provider Demographics
NPI:1235181736
Name:BRODIE, MICHAEL LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
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 1:1145 GEER RD
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95380-3381
Mailing Address - Country:US
Mailing Address - Phone:209-656-9517
Mailing Address - Fax:209-656-9545
Practice Address - Street 1:1145 GEER RD
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380-3381
Practice Address - Country:US
Practice Address - Phone:209-656-9517
Practice Address - Fax:209-656-9870
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA031978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A319870Medicaid
CAA84292Medicare UPIN
CA00A319780Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER