Provider Demographics
NPI:1780864934
Name:BRODRICK, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:BRODRICK
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 1:740 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3282
Mailing Address - Country:US
Mailing Address - Phone:386-734-9122
Mailing Address - Fax:386-736-4348
Practice Address - Street 1:1053 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8260
Practice Address - Country:US
Practice Address - Phone:386-774-2500
Practice Address - Fax:833-450-4859
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0013528207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056451600Medicaid
FLD64224Medicare UPIN
FL48794Medicare PIN