Provider Demographics
NPI:1720190879
Name:BROADWELL, RICHARD OLLEN III (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:OLLEN
Last Name:BROADWELL
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:833 N SPENCE AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4267
Mailing Address - Country:US
Mailing Address - Phone:919-920-3595
Mailing Address - Fax:919-731-2048
Practice Address - Street 1:833 N SPENCE AVE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530
Practice Address - Country:US
Practice Address - Phone:919-731-2023
Practice Address - Fax:919-731-2048
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC23478208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD29021Medicare UPIN