Provider Demographics
NPI:1326046921
Name:BRODIN, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BRODIN
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:PO BOX 745
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-0745
Mailing Address - Country:US
Mailing Address - Phone:914-625-8600
Mailing Address - Fax:888-254-5368
Practice Address - Street 1:16400 SODA SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95033-8621
Practice Address - Country:US
Practice Address - Phone:914-625-8600
Practice Address - Fax:888-254-5368
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142123-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB17292Medicare UPIN
NY63A65HW561Medicare PIN