Provider Demographics
NPI:1609821891
Name:BRODERICK, KELLY CLARK (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CLARK
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:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:415-883-3406
Practice Address - Street 1:100 S SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3805
Practice Address - Country:US
Practice Address - Phone:650-696-4515
Practice Address - Fax:650-696-4626
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG787592085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G787590Medicaid
CA300121792OtherRAILROAD MEDICARE
CA00G787590OtherBLUE CROSS
CA300121755OtherRAILROAD MEDICARE
CA00G787594Medicare PIN
CA00G787590OtherBLUE CROSS
CA00G787590Medicare PIN
CA00G787952Medicare PIN
CAG51204Medicare UPIN
CA00G787593Medicare PIN