Provider Demographics
NPI:1689679326
Name:BRODER-OLDACH, RICHARD E (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:BRODER-OLDACH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 WARDS CORNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-6966
Mailing Address - Country:US
Mailing Address - Phone:513-707-4041
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:150 HEALTH PARTNER CIRCLE
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-9422
Practice Address - Country:US
Practice Address - Phone:937-444-2514
Practice Address - Fax:937-444-4818
Is Sole Proprietor?:No
Enumeration Date:2005-06-18
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006887207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080076704OtherRAILROAD
OH2066642Medicaid
OHG82488Medicare UPIN
OHBR2018841Medicare PIN