Provider Demographics
NPI:1881858363
Name:BRODER, LAURA EVAVOLD (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:EVAVOLD
Last Name:BRODER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:CORINNE
Other - Last Name:EVAVOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:PO BOX 1309 MAIL STOP 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-993-4001
Mailing Address - Fax:
Practice Address - Street 1:1885 PLAZA DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2979
Practice Address - Country:US
Practice Address - Phone:952-993-4001
Practice Address - Fax:952-993-4095
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine