Provider Demographics
NPI:1750374591
Name:BROAD, WILLIAM GOWING (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GOWING
Last Name:BROAD
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 1:15425 LOS GATOS BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2541
Mailing Address - Country:US
Mailing Address - Phone:408-340-5700
Mailing Address - Fax:
Practice Address - Street 1:15425 LOS GATOS BLVD STE 120
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2541
Practice Address - Country:US
Practice Address - Phone:408-340-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G671570OtherMCR UPIN
E92743Medicare UPIN