Provider Demographics
NPI:1376571562
Name:BRODERICK-VILLA, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:BRODERICK-VILLA
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 1:2345 COUNTRY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-7319
Mailing Address - Country:US
Mailing Address - Phone:925-418-0278
Mailing Address - Fax:
Practice Address - Street 1:365 HAWTHORNE AVE
Practice Address - Street 2:101
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3107
Practice Address - Country:US
Practice Address - Phone:510-465-5523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82944208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA129740Medicare UPIN