Provider Demographics
NPI:1710097985
Name:BROADHEAD, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BROADHEAD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:401 W 2ND STREET
Mailing Address - Street 2:227
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-5345
Mailing Address - Country:US
Mailing Address - Phone:775-784-1223
Mailing Address - Fax:775-327-2006
Practice Address - Street 1:401 W 2ND STREET
Practice Address - Street 2:#216
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5345
Practice Address - Country:US
Practice Address - Phone:775-784-6388
Practice Address - Fax:775-784-1428
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-02-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NV95652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016871Medicaid
NVC75742Medicare UPIN
NV002016871Medicaid