Healthcare Provider Details

I. General information

NPI: 1306049572
Provider Name (Legal Business Name): SAMUEL BRODER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8612 HONEYBEE LN
BETHESDA MD
20817-6941
US

IV. Provider business mailing address

8612 HONEYBEE LN
BETHESDA MD
20817-6941
US

V. Phone/Fax

Practice location:
  • Phone: 240-453-3300
  • Fax: 240-453-3074
Mailing address:
  • Phone: 240-453-3300
  • Fax: 240-453-3074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License NumberD0017618
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: