Provider Demographics
NPI:1437241890
Name:BRODSKY, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:BRODSKY
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 849
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-0659
Mailing Address - Country:US
Mailing Address - Phone:631-689-9087
Mailing Address - Fax:
Practice Address - Street 1:45 UPPER SHEEP PASTURE RD
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1745
Practice Address - Country:US
Practice Address - Phone:631-689-9087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00644413Medicaid
538271Medicare ID - Type Unspecified
NY00644413Medicaid