Provider Demographics
NPI:1528039526
Name:BROUDY, ABRAHAM E (MD)
Entity Type:Individual
Prefix:DR
First Name:ABRAHAM
Middle Name:E
Last Name:BROUDY
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 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-636-4300
Mailing Address - Fax:858-636-4319
Practice Address - Street 1:2440 FENTON ST.
Practice Address - Street 2:STE. 100
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914
Practice Address - Country:US
Practice Address - Phone:619-656-3040
Practice Address - Fax:619-656-3045
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71609208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA71609OtherMD LICENSE