Provider Demographics
NPI:1710932009
Name:BRODSKY, IVAN LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:LOUIS
Last Name:BRODSKY
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 1:4225 GOLDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4215
Mailing Address - Country:US
Mailing Address - Phone:763-588-0661
Mailing Address - Fax:763-287-2310
Practice Address - Street 1:4225 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4215
Practice Address - Country:US
Practice Address - Phone:763-588-0661
Practice Address - Fax:763-302-4345
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN187992084N0400X
WI437412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0265003OtherPREFERRED ONE
MN0500353OtherMEDICA
MN183070800Medicaid
WI30204400Medicaid
MN02062BROtherBCBS OF MN
MN22782OtherAMERICA'S PPO
IA0507376Medicaid
MNHP12967OtherHEALTHPARTNERS
MN100279C029OtherUCARE
MN130004298OtherRAILROAD MEDICARE