Healthcare Provider Details

I. General information

NPI: 1750336475
Provider Name (Legal Business Name): IAN BRODRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MOUNT HOPE AVE
ROCKAWAY NJ
07866-1645
US

IV. Provider business mailing address

PO BOX 416457
BOSTON MA
02241-6457
US

V. Phone/Fax

Practice location:
  • Phone: 973-895-6601
  • Fax: 973-895-5324
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMA48910
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: