Provider Demographics
NPI:1831602184
Name:BRODER, ETHAN PAUL
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:PAUL
Last Name:BRODER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 STANFORD DR
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2001
Mailing Address - Country:US
Mailing Address - Phone:203-885-6489
Mailing Address - Fax:
Practice Address - Street 1:1101 STANFORD DR
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2001
Practice Address - Country:US
Practice Address - Phone:203-885-6489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program