Provider Demographics
NPI:1477727055
Name:BRODAK, MATTHEW (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BRODAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9673 LOST KNIFE RD
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2622
Mailing Address - Country:US
Mailing Address - Phone:301-330-4265
Mailing Address - Fax:301-963-4508
Practice Address - Street 1:9673 LOST KNIFE RD
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2622
Practice Address - Country:US
Practice Address - Phone:301-330-4265
Practice Address - Fax:301-963-4508
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1115152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD214308900Medicaid