Provider Demographics
NPI:1326107350
Name:BROADDUS, ROBERT M (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:BROADDUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13839 S MUR LEN RD STE A
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1661
Mailing Address - Country:US
Mailing Address - Phone:913-782-5993
Mailing Address - Fax:
Practice Address - Street 1:13839 S MUR LEN RD STE A
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1661
Practice Address - Country:US
Practice Address - Phone:913-782-5993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1591152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1591OtherSTATE LICENSE
MO30592028OtherBLUE CROSS BLUE SHIELD
J95B299Medicare ID - Type Unspecified
MO30592028OtherBLUE CROSS BLUE SHIELD