Provider Demographics
NPI:1851554786
Name:BROADWELL, AARON WILTON (MD)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:WILTON
Last Name:BROADWELL
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 1:820 JORDAN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4518
Mailing Address - Country:US
Mailing Address - Phone:318-221-0399
Mailing Address - Fax:
Practice Address - Street 1:820 JORDAN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4518
Practice Address - Country:US
Practice Address - Phone:318-221-0399
Practice Address - Fax:318-221-1940
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.205607207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology