Provider Demographics
NPI:1942209911
Name:BROD, PATRICK JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOHN
Last Name:BROD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1500 CURVE CREST BLVD W
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6040
Mailing Address - Country:US
Mailing Address - Phone:651-439-1234
Mailing Address - Fax:651-439-1547
Practice Address - Street 1:927 CHURCHILL ST W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6605
Practice Address - Country:US
Practice Address - Phone:651-439-5330
Practice Address - Fax:651-430-4528
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN916470700Medicaid
WI34293400Medicaid
P00370803Medicare PIN
MN916470700Medicaid
MN080015135Medicare PIN