Provider Demographics
NPI:1013901750
Name:BROESKE, DANIEL J (MD)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:J
Last Name:BROESKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 S MARYLAND PKWY
Mailing Address - Street 2:STE 408
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2307
Mailing Address - Country:US
Mailing Address - Phone:702-733-8018
Mailing Address - Fax:702-733-8751
Practice Address - Street 1:3121 S MARYLAND PKWY
Practice Address - Street 2:STE 408
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2307
Practice Address - Country:US
Practice Address - Phone:702-733-8018
Practice Address - Fax:702-733-8751
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVF68259Medicare UPIN
NV100260Medicare PIN