Provider Demographics
NPI:1538133327
Name:BRODERICK-BREIT, DARLA J (DO)
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:J
Last Name:BRODERICK-BREIT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3838 W NEPTUNE ST STE D5
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5841
Mailing Address - Country:US
Mailing Address - Phone:813-837-0221
Mailing Address - Fax:813-832-2973
Practice Address - Street 1:3838 W NEPTUNE ST STE D5
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5841
Practice Address - Country:US
Practice Address - Phone:813-837-0221
Practice Address - Fax:813-832-2973
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS07307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253699400Medicaid
FL57490ZMedicare PIN
FL253699400Medicaid