Provider Demographics
NPI:1760424824
Name:BRODHEAD, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BRODHEAD
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5100
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40682207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A406820OtherBLUE SHIELD
CA1902846306OtherGROUP NPI
CACE1617OtherGROUP RAILROAD MEDICARE
CAGR0016910OtherGROUP MEDICAID PIN
CAW11675OtherGROUP MEDICARE PIN
CAW18762OtherGROUP MEDICARE
CA00A406820197OtherCAL OPTIMA
CA110172624OtherRALILROAD MEDICARE
CA1356390009OtherGROUP NPI
CAGR0100430OtherGROUP MEDICAL
CA00A406820Medicaid
CACE1617OtherGROUP RAILROAD MEDICARE
CAWA40682AMedicare PIN