Provider Demographics
NPI:1750451712
Name:BRODA, MICHAEL MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MARK
Last Name:BRODA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15627 CHIPPING DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-2286
Mailing Address - Country:US
Mailing Address - Phone:704-992-0259
Mailing Address - Fax:
Practice Address - Street 1:9605 CALDWELL COMMONS CIR
Practice Address - Street 2:SUITE C
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8138
Practice Address - Country:US
Practice Address - Phone:704-987-9818
Practice Address - Fax:704-987-9718
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3157111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC085MJOtherBCBS NUMBER