Healthcare Provider Details

I. General information

NPI: 1558467514
Provider Name (Legal Business Name): CORRIE D BROUDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FIR ST
SAN DIEGO CA
92101-2327
US

IV. Provider business mailing address

300 FIR ST
SAN DIEGO CA
92101-2327
US

V. Phone/Fax

Practice location:
  • Phone: 619-446-1539
  • Fax: 619-446-1569
Mailing address:
  • Phone: 619-446-1539
  • Fax: 619-446-1569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberA82832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: