Healthcare Provider Details

I. General information

NPI: 1942594767
Provider Name (Legal Business Name): MOLLY C BRODER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 BAINBRIDGE AVE ROSENTHAL 4, DEPARTMENT OF PEDIATRICS
BRONX NY
10467-2403
US

IV. Provider business mailing address

14 ELM PL
BRONX NY
10465-3908
US

V. Phone/Fax

Practice location:
  • Phone: 718-741-2467
  • Fax:
Mailing address:
  • Phone: 617-276-5549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number260957
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: