Provider Demographics
NPI:1649517921
Name:BRODIE, FRED JOSEPH (DIVE IDC)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:JOSEPH
Last Name:BRODIE
Suffix:
Gender:M
Credentials:DIVE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2952 WELLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5740
Mailing Address - Country:US
Mailing Address - Phone:808-554-4533
Mailing Address - Fax:
Practice Address - Street 1:2930 TARAWA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5198
Practice Address - Country:US
Practice Address - Phone:619-437-5962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman