Provider Demographics
NPI:1629033493
Name:BROYLES, BRAD (MD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BROYLES
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:PO BOX 491000
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-1000
Mailing Address - Country:US
Mailing Address - Phone:352-315-7500
Mailing Address - Fax:352-360-6582
Practice Address - Street 1:2018 TALLEY RD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3426
Practice Address - Country:US
Practice Address - Phone:352-315-7500
Practice Address - Fax:352-360-6582
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 00713072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263317500Medicaid
FL03386OtherBLUE CROSS BLUE SHIELD #
FL03386OtherBLUE CROSS BLUE SHIELD #
FLE8689ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FL263317500Medicaid