Provider Demographics
NPI:1588666424
Name:BRODERICK, JOHN DENNIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DENNIS
Last Name:BRODERICK
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 1:15 FENIMORE PL
Mailing Address - Street 2:
Mailing Address - City:GANSEVOORT
Mailing Address - State:NY
Mailing Address - Zip Code:12831-1476
Mailing Address - Country:US
Mailing Address - Phone:518-306-5908
Mailing Address - Fax:
Practice Address - Street 1:7755 CENTER AVE STE 630
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-9152
Practice Address - Country:US
Practice Address - Phone:657-400-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210877-2207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01862431Medicaid
NY01862431Medicaid
NYBB1994Medicare ID - Type Unspecified