Healthcare Provider Details

I. General information

NPI: 1417152232
Provider Name (Legal Business Name): LORI BRODERICK M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 BIRMINGHAM WAY
SAN DIEGO CA
92123-2758
US

IV. Provider business mailing address

3020 CHILDRENS WAY MC5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5961
  • Fax:
Mailing address:
  • Phone: 858-309-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA106397
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA106397
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: