Provider Demographics
NPI:1568672459
Name:BRODERICK, THERESA (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BRODERICK
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 1:23 MANHATTAN SQ
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5843
Mailing Address - Country:US
Mailing Address - Phone:757-224-1600
Mailing Address - Fax:757-825-1316
Practice Address - Street 1:23 MANHATTAN SQ
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5843
Practice Address - Country:US
Practice Address - Phone:757-224-1600
Practice Address - Fax:757-825-1316
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics