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General NPI Number Information
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NPI Number | 1609821891
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Entity Type | Individual
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Provider Name | KELLY CLARK BRODERICK M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/24/2006
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Last Update Date | 09/23/2020
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Provider Practice Location Address
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Address Line | 100 S SAN MATEO DR
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City | SAN MATEO
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State | CA
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Zip | 94401-3805
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Country | US
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Telephone | 650-696-4515
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Fax | 650-696-4626
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Provider Business Mailing Address
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Address Line | PO BOX 6102
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City | NOVATO
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State | CA
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Zip | 94948-6102
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Country | US
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Telephone | 415-884-3418
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Fax | 415-883-3406
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085U0001X
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Taxonomy Name | Diagnostic Ultrasound Physician
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License Number | G78759
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | G78759
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License Number State | CA
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