Provider Demographics
NPI:1275538423
Name:BRODSKY, MICHAEL A (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:BRODSKY
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 1:801 N TUSTIN AVE
Mailing Address - Street 2:#706
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3612
Mailing Address - Country:US
Mailing Address - Phone:714-568-6600
Mailing Address - Fax:714-245-0260
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:SUITE 706
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3612
Practice Address - Country:US
Practice Address - Phone:714-568-6600
Practice Address - Fax:714-245-0260
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD11837174400000X, 207RC0001X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI57286901Medicaid
CAGR0059850Medicaid
HI0000255315OtherHMSA BILLING NUMBER
HI0000255315OtherHMSA BILLING NUMBER
CAGR0059850Medicaid
HI57286901Medicaid
CAW15717Medicare PIN