Provider Demographics
NPI:1952389538
Name:BRODEUR, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BRODEUR
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:PO BOX 860554
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-0554
Mailing Address - Country:US
Mailing Address - Phone:904-346-3606
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:3625 UNIVERSITY BLVD S
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4207
Practice Address - Country:US
Practice Address - Phone:904-346-3606
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0090285207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL44098OtherBCBS
FL269864100OtherFLORIDA MEDICAID
FLP00139639OtherRRMCR
FL269864100Medicaid
P00139639OtherRAILROAD MEDICARE
GA787365756AMedicaid
FLP00139639OtherRRMCR
FL44098ZMedicare ID - Type Unspecified