Provider Demographics
NPI:1255498168
Name:BRODHEAD, STEVEN J (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:J
Last Name:BRODHEAD
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 1:697 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-1260
Mailing Address - Country:US
Mailing Address - Phone:617-527-1418
Mailing Address - Fax:
Practice Address - Street 1:697 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-1260
Practice Address - Country:US
Practice Address - Phone:617-527-1418
Practice Address - Fax:617-964-1417
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3287152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0354449Medicaid
MA0882450001Medicare NSC