Provider Demographics
NPI:1629029822
Name:BRODALE, SEAN D (DO)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:D
Last Name:BRODALE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18754 US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52537-6803
Mailing Address - Country:US
Mailing Address - Phone:641-664-1799
Mailing Address - Fax:641-664-1663
Practice Address - Street 1:18754 US HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:IA
Practice Address - Zip Code:52537-6803
Practice Address - Country:US
Practice Address - Phone:641-664-1799
Practice Address - Fax:641-664-1663
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3485204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209029206Medicaid
IA2424325Medicaid
IAI17875Medicare PIN
H22956Medicare UPIN