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General NPI Number Information
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NPI Number | 1639188394
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Entity Type | Individual
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Provider Name | KEVIN STANLEY BROADDRICK DPM
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Gender | Male
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 08/11/2023
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Provider Practice Location Address
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Address Line | 6739 W CACTUS RD
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City | PEORIA
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State | AZ
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Zip | 85381-5311
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Country | US
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Telephone | 833-242-0100
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Fax | 602-805-4745
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Provider Business Mailing Address
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Address Line | 3149 E HAZELTINE WAY
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City | CHANDLER
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State | AZ
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Zip | 85249-9066
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Country | US
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Telephone | 414-702-0954
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Fax |
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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 | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | POD-000814
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License Number State | AZ
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