Provider Demographics
NPI:1780189050
Name:BRODWATER, WILLIAM WESLEY IV (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WESLEY
Last Name:BRODWATER
Suffix:IV
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 1:551 RIVERHILL CIR APT 833
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-8152
Mailing Address - Country:US
Mailing Address - Phone:304-904-7124
Mailing Address - Fax:
Practice Address - Street 1:1 PERKINS SQ
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1063
Practice Address - Country:US
Practice Address - Phone:330-543-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.245882208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics