Provider Demographics
NPI:1336392604
Name:KEVIN W. BRODER, M. D. INCORPORATED
Entity Type:Organization
Organization Name:KEVIN W. BRODER, M. D. INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-453-5344
Mailing Address - Street 1:3535 LEBON DR
Mailing Address - Street 2:UNIT 3204
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-4593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8899 UNIVERSITY CENTER LN
Practice Address - Street 2:SUITE 350
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1013
Practice Address - Country:US
Practice Address - Phone:858-453-5344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82409208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty