Provider Demographics
NPI:1679583769
Name:LAWRENCE E BRODER M D P A
Entity Type:Organization
Organization Name:LAWRENCE E BRODER M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-238-1212
Mailing Address - Street 1:8740 SW 182ND TER
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-5952
Mailing Address - Country:US
Mailing Address - Phone:305-238-1212
Mailing Address - Fax:305-238-8191
Practice Address - Street 1:45 NW 8TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4452
Practice Address - Country:US
Practice Address - Phone:305-246-5500
Practice Address - Fax:305-246-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027628207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL210135OtherAMERIGROUP HMO
FL221246OtherAVMED HMO
FL370009700Medicaid
FL55027OtherJMH HMO
FL370009700Medicaid
FL=========OtherHUMANA HEALTH CARE
FL210135OtherAMERIGROUP HMO
FL221246OtherAVMED HMO
FL=========OtherVISTA HMO