Provider Demographics
NPI:1982737144
Name:BRODKIN, ROGER H (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:H
Last Name:BRODKIN
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 1:101 OLD SHORT HILLS RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1000
Mailing Address - Country:US
Mailing Address - Phone:973-736-9535
Mailing Address - Fax:973-736-2607
Practice Address - Street 1:101 OLD SHORT HILLS RD
Practice Address - Street 2:SUITE 401
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1000
Practice Address - Country:US
Practice Address - Phone:973-736-9535
Practice Address - Fax:973-736-2607
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA01730100207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
527145Medicare ID - Type Unspecified
NJC53715Medicare UPIN