Healthcare Provider Details

I. General information

NPI: 1639188394
Provider Name (Legal Business Name): KEVIN STANLEY BROADDRICK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6739 W CACTUS RD
PEORIA AZ
85381-5311
US

IV. Provider business mailing address

3149 E HAZELTINE WAY
CHANDLER AZ
85249-9066
US

V. Phone/Fax

Practice location:
  • Phone: 833-242-0100
  • Fax: 602-805-4745
Mailing address:
  • Phone: 414-702-0954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD-000814
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: