Provider Demographics
NPI:1578752986
Name:GENE M BROTH MD INC
Entity Type:Organization
Organization Name:GENE M BROTH MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-996-4242
Mailing Address - Street 1:2925 SYCAMORE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1207
Mailing Address - Country:US
Mailing Address - Phone:805-522-0333
Mailing Address - Fax:805-522-4230
Practice Address - Street 1:2925 SYCAMORE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1207
Practice Address - Country:US
Practice Address - Phone:805-522-0333
Practice Address - Fax:805-522-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACO26169208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW707AMedicare PIN