Provider Demographics
NPI:1972512424
Name:KOOLMAN, BRODERRICK DARRELL (DC)
Entity Type:Individual
Prefix:DR
First Name:BRODERRICK
Middle Name:DARRELL
Last Name:KOOLMAN
Suffix:
Gender:M
Credentials:DC
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 34722
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78265-4722
Mailing Address - Country:US
Mailing Address - Phone:210-735-0588
Mailing Address - Fax:210-735-3823
Practice Address - Street 1:1213 BASSE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-1007
Practice Address - Country:US
Practice Address - Phone:210-735-0588
Practice Address - Fax:210-735-3823
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5620111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU38483Medicare UPIN