Provider Demographics
NPI:1639134604
Name:BRODIE, JONATHAN J (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:J
Last Name:BRODIE
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 1:200 E TYRANENA PARK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-9678
Mailing Address - Country:US
Mailing Address - Phone:920-648-3113
Mailing Address - Fax:
Practice Address - Street 1:200 E TYRANENA PARK RD
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-9678
Practice Address - Country:US
Practice Address - Phone:920-648-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30363207P00000X
WI30363-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C08681Medicare UPIN
WI008000240Medicare ID - Type Unspecified