Healthcare Provider Details

I. General information

NPI: 1285645002
Provider Name (Legal Business Name): PETER BRODERICK M.D., M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PARADISE RD SUITE E
MODESTO CA
95351-3104
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD SUITE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-4000
  • Fax: 209-558-5036
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG63629
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: