Provider Demographics
NPI:1275573081
Name:BROADHEAD, BRIAN G (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
Last Name:BROADHEAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FLORISSANT OAKS SHOP CTR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-3933
Mailing Address - Country:US
Mailing Address - Phone:314-837-8477
Mailing Address - Fax:314-837-0611
Practice Address - Street 1:111 FLORISSANT OAKS SHOP CTR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-3933
Practice Address - Country:US
Practice Address - Phone:314-837-8477
Practice Address - Fax:314-837-0611
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014944213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU95611Medicare UPIN
MO003011601Medicare ID - Type Unspecified