Provider Demographics
NPI:1821196601
Name:BROADWATER, RONALD LEE SR (MD)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:LEE
Last Name:BROADWATER
Suffix:SR
Gender:M
Credentials:MD
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Mailing Address - Street 1:12 BRECON PL
Mailing Address - Street 2:STE 400
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-2343
Mailing Address - Country:US
Mailing Address - Phone:443-281-8086
Mailing Address - Fax:443-281-8117
Practice Address - Street 1:12 BRECON PL
Practice Address - Street 2:STE 400
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-2343
Practice Address - Country:US
Practice Address - Phone:443-281-8086
Practice Address - Fax:443-281-8117
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-03-06
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Provider Licenses
StateLicense IDTaxonomies
MDD0015200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1860RLMedicare ID - Type Unspecified
D75251Medicare UPIN