Provider Demographics
NPI:1396183158
Name:HOWARD, BRODERICK C (DO)
Entity Type:Individual
Prefix:
First Name:BRODERICK
Middle Name:C
Last Name:HOWARD
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Gender:M
Credentials:DO
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Mailing Address - Street 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0741
Practice Address - Street 1:611 E DOUGLAS RD
Practice Address - Street 2:STE 137
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-335-6214
Practice Address - Fax:574-335-0772
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2016-09-14
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Provider Licenses
StateLicense IDTaxonomies
IN11017346A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02004814AOtherIN MEDICAL LICENSE