Provider Demographics
NPI:1891915021
Name:BRODERICK, KRISTEN PARKER (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:PARKER
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4940 EASTERN AVE
Mailing Address - Street 2:SUITE A520
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2735
Mailing Address - Country:US
Mailing Address - Phone:410-550-0407
Mailing Address - Fax:410-550-1808
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:SUITE A520
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0407
Practice Address - Fax:410-550-1808
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00808742086S0122X
MO2012011212086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery