Provider Demographics
NPI:1558467514
Name:BROUDY, CORRIE D (MD)
Entity Type:Individual
Prefix:DR
First Name:CORRIE
Middle Name:D
Last Name:BROUDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FIR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2327
Mailing Address - Country:US
Mailing Address - Phone:619-446-1539
Mailing Address - Fax:619-446-1569
Practice Address - Street 1:300 FIR ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2327
Practice Address - Country:US
Practice Address - Phone:619-446-1539
Practice Address - Fax:619-446-1569
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82832207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FHC18880FOtherMEDI CAL
W5740Medicare ID - Type Unspecified
I33910Medicare UPIN