Provider Demographics
NPI:1659313963
Name:BROUDER, DANIEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:BROUDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 JACK MARTIN BLVD
Mailing Address - Street 2:SUITE D-1
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7771
Mailing Address - Country:US
Mailing Address - Phone:732-458-5067
Mailing Address - Fax:732-458-4962
Practice Address - Street 1:210 JACK MARTIN BLVD
Practice Address - Street 2:SUITE D-1
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7771
Practice Address - Country:US
Practice Address - Phone:732-458-5067
Practice Address - Fax:732-458-4962
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07572700207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0052078Medicaid
P00053546OtherRAILROADMEDICARENUMBER
P00053546OtherRAILROADMEDICARENUMBER
H29973Medicare UPIN