Provider Demographics
NPI:1356563258
Name:BRODIE, KRISTIN ROYCE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:ROYCE
Last Name:BRODIE
Suffix:
Gender:F
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:PO BOX 382
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER CORNERS
Mailing Address - State:VT
Mailing Address - Zip Code:05035-0382
Mailing Address - Country:US
Mailing Address - Phone:315-436-8864
Mailing Address - Fax:
Practice Address - Street 1:123 FANCHER RD
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER CORNERS
Practice Address - State:VT
Practice Address - Zip Code:05035-9736
Practice Address - Country:US
Practice Address - Phone:315-436-8864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178242-01207Y00000X
NY1782421207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01132609Medicaid
NY01132609Medicaid