1336307529 NPI number — MR. ARKADY BRODER MD

Table of content: MR. ARKADY BRODER MD (NPI 1336307529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336307529 NPI number — MR. ARKADY BRODER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODER
Provider First Name:
ARKADY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336307529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1640 RT 88W
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
BRICK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-458-8300
Provider Business Mailing Address Fax Number:
732-458-8529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 RT 88W
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
BRICK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-458-8300
Provider Business Practice Location Address Fax Number:
732-458-8529
Provider Enumeration Date:
05/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  60255303 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 25MA09209900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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