Provider Demographics
NPI:1770893471
Name:MICHAEL O. BRODER, OD, PA
Entity type:Organization
Organization Name:MICHAEL O. BRODER, OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-493-8787
Mailing Address - Street 1:2165 TAMIAMI TRL S
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5034
Mailing Address - Country:US
Mailing Address - Phone:941-493-8787
Mailing Address - Fax:941-408-8446
Practice Address - Street 1:2165 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5034
Practice Address - Country:US
Practice Address - Phone:941-493-8787
Practice Address - Fax:941-408-8446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0002949152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU61162Medicare PIN