Provider Demographics
NPI:1255498507
Name:BROSTOFF, LAURENCE M (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:M
Last Name:BROSTOFF
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 1:10452 SILVERDALE WAY NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9411
Mailing Address - Country:US
Mailing Address - Phone:360-307-7300
Mailing Address - Fax:
Practice Address - Street 1:10452 SILVERDALE WAY NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9411
Practice Address - Country:US
Practice Address - Phone:360-307-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61694207R00000X
WAMD00029903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8143935Medicaid
WAG8878923Medicare PIN
WAG8878922Medicare PIN
WA110206438Medicare PIN
WA8143935Medicaid
WAE86793Medicare UPIN