Doctor Name: | MR. EDWARD BRODERICK |
NPI Number: | 1083877492 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | OPT. |
License Number: | CT0648 |
Business Practice Address: | 77 Hazard Ave Enfield, CT - 060823890 |
Business Phone Number: | 8507454426 |
Business Fax Number: | |
Mailing Address: | 77 Hazard Ave, ENFIELD |
State: | CT |
Postal Code: | 060823890 |
Phone Number: | 8607454426 |
Fax Number: | |
NPI Enumeration Date: | 07/07/2008 |
NPI Last Update Date: | 07/07/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 156FX1800X |
License Number: | CT0648 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | CT |
Taxonomy Type: | Eye and Vision Services Providers |
Taxonomy Classification: | Technician/Technologist |
Taxonomy Specialization: | Optician |
Taxonomy Definition: |