Healthcare Provider Details

I. General information

NPI: 1831500628
Provider Name (Legal Business Name): NOAM BRODER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD # B220
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-5252
  • Fax: 310-423-8441
Mailing address:
  • Phone: 310-967-1780
  • Fax: 866-991-4287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA164383
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberA164383
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: