Provider Demographics
NPI:1285645002
Name:BRODERICK, PETER (MD, MED)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:MD, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:401 PARADISE RD
Practice Address - Street 2:SUITE E
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-3104
Practice Address - Country:US
Practice Address - Phone:209-558-4000
Practice Address - Fax:209-558-5036
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63629207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G636290Medicare ID - Type UnspecifiedMCR INDIVIDUAL
E50216Medicare UPIN