Provider Demographics
NPI:1457330912
Name:BRODY, RICHARD L (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:BRODY
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 1:1315 MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1948
Mailing Address - Country:US
Mailing Address - Phone:860-450-7471
Mailing Address - Fax:
Practice Address - Street 1:1315 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1948
Practice Address - Country:US
Practice Address - Phone:860-450-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT142207207Q00000X
CT42207207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010042204CT01OtherANTHEM BCBS (GENERATIONS)
145674OtherCONNECTICARE
CT3985938OtherAETNA CLAIMS (GENERATIONS)
CT3487457015OtherCIGNA (GENERATIONS)
CT001422071Medicaid
CT080001731OtherMEDICARE PIN (GENERATIONS)
CTPAROtherCHN-PPO (GENERATIONS)
CT11113774OtherHMC-PPO / MULTIPLAN (GENERATIONS)
CT1457330912OtherCIGNA
CT007733871OtherMEDICAID (GENERATIONS)
CT145674-G525OtherCONNECTICARE (GENERATIONS)
CT2444498OtherWELLCARE (GENERATIONS)
CTP3319349OtherOXFORD (GENERATIONS)
7896129OtherAETNA
CT2V5016OtherHEALTHNET (GENERATIONS)
CT2444498OtherWELLCARE (GENERATIONS)
CT145674-G525OtherCONNECTICARE (GENERATIONS)
CTPAROtherCHN-PPO (GENERATIONS)