Provider Demographics
NPI:1720617558
Name:BROUGHTON, PETER BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:BRADLEY
Last Name:BROUGHTON
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 1:8901 WISCONSIN AVE
Mailing Address - Street 2:4TH FLOOR, AMERICA BLDG
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889
Mailing Address - Country:US
Mailing Address - Phone:301-319-5437
Mailing Address - Fax:
Practice Address - Street 1:77 NEALY AVE
Practice Address - Street 2:633D MEDICAL GROUP
Practice Address - City:JOINT BASE LANGLEY-EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:937-607-7205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012729842083A0100X, 208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program