Provider Demographics
NPI:1407203060
Name:BRODDUS, ROBERT W JR (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:W
Last Name:BRODDUS
Suffix:JR
Gender:M
Credentials:LAT, ATC
Other - Prefix:
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Mailing Address - Street 1:124 DREXLER AVE S
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6634
Mailing Address - Country:US
Mailing Address - Phone:315-382-8107
Mailing Address - Fax:
Practice Address - Street 1:1101 CAMDEN AVE
Practice Address - Street 2:SALISBURY UNIVERSITY
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-6837
Practice Address - Country:US
Practice Address - Phone:410-543-6355
Practice Address - Fax:410-546-2639
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDA00007582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer