Provider Demographics
NPI:1669634234
Name:BROADDUS, BRIAN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MARK
Last Name:BROADDUS
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 5587
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-5587
Mailing Address - Country:US
Mailing Address - Phone:409-838-5214
Mailing Address - Fax:
Practice Address - Street 1:755 N 11TH ST
Practice Address - Street 2:SUITE P3600
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1501
Practice Address - Country:US
Practice Address - Phone:409-838-5214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4961207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology