Provider Demographics
NPI:1265084537
Name:BRODERICK, JOHN MARCUS
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MARCUS
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-4031
Mailing Address - Country:US
Mailing Address - Phone:318-955-2110
Mailing Address - Fax:
Practice Address - Street 1:7946 GOODWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7629
Practice Address - Country:US
Practice Address - Phone:225-590-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator