Provider Demographics
NPI:1790870905
Name:BROADWAY, ERIC S (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:S
Last Name:BROADWAY
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 179
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-0179
Mailing Address - Country:US
Mailing Address - Phone:918-967-4560
Mailing Address - Fax:918-967-4582
Practice Address - Street 1:1505 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-2913
Practice Address - Country:US
Practice Address - Phone:918-967-3368
Practice Address - Fax:918-967-4582
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK169562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100119810AMedicaid
OK16956OtherMEDICAL LICENSE
OK16956OtherMEDICAL LICENSE
OK100119810AMedicaid