Provider Demographics
NPI:1609301779
Name:BROADWATER, DEVIN REESE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEVIN
Middle Name:REESE
Last Name:BROADWATER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:150 REYNOIR ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-4130
Practice Address - Country:US
Practice Address - Phone:228-432-1571
Practice Address - Fax:419-866-5453
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE31052208D00000X
MS29686207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice