Healthcare Provider Details

I. General information

NPI: 1457330912
Provider Name (Legal Business Name): RICHARD L BRODY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 MAIN ST SUITE 2
WILLIMANTIC CT
06226-1948
US

IV. Provider business mailing address

1315 MAIN ST SUITE 2
WILLIMANTIC CT
06226-1948
US

V. Phone/Fax

Practice location:
  • Phone: 860-450-7471
  • Fax:
Mailing address:
  • Phone: 860-450-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number142207
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number42207
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: