Healthcare Provider Details

I. General information

NPI: 1003940032
Provider Name (Legal Business Name): WALTER G BROADNAX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 FAIR LN
CINCINNATI OH
45227-3401
US

IV. Provider business mailing address

1220 PADDOCK HILLS AVE
CINCINNATI OH
45229-1218
US

V. Phone/Fax

Practice location:
  • Phone: 513-421-7246
  • Fax: 513-421-7796
Mailing address:
  • Phone: 513-421-7246
  • Fax: 513-421-7796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number35060685
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: