Healthcare Provider Details

I. General information

NPI: 1699849349
Provider Name (Legal Business Name): TODD BRODER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

PO BOX 103424
GAINESVILLE FL
32610-3424
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-5155
  • Fax:
Mailing address:
  • Phone: 352-265-7981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME97336
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberME97336
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: