Provider Demographics
NPI:1982635157
Name:BRODER, ROBERT IRVING (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:IRVING
Last Name:BRODER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 11673
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-0673
Mailing Address - Country:US
Mailing Address - Phone:703-820-2212
Mailing Address - Fax:703-379-9575
Practice Address - Street 1:301B PARK HILL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3375
Practice Address - Country:US
Practice Address - Phone:540-310-0041
Practice Address - Fax:703-379-9575
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027292207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC61529Medicare UPIN