| Doctor Name: | DR. WALLACE BROADBENT |
| NPI Number: | 1861443202 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.O. |
| License Number: | 5101011784 |
| Business Practice Address: | 1535 Gull Rd Msb 015 Kalamazoo, MI - 490481650 |
| Business Phone Number: | 2692266933 |
| Business Fax Number: | 2692266949 |
| Mailing Address: | 1535 Gull Rd, Msb 015 KALAMAZOO |
| State: | MI |
| Postal Code: | 490481650 |
| Phone Number: | 2692266933 |
| Fax Number: | 2692266949 |
| NPI Enumeration Date: | 05/12/2006 |
| NPI Last Update Date: | 02/10/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 5101011784 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MI |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |