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General NPI Number Information
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NPI Number | 1770893471
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Entity Type | Organization
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Legal Business Name | MICHAEL O. BRODER, OD, PA
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Dates
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Enumeration Date | 10/15/2010
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Last Update Date | 10/27/2010
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Provider Practice Location Address
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Address Line | 2165 TAMIAMI TRL S
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City | VENICE
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State | FL
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Zip | 34293-5034
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Country | US
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Telephone | 941-493-8787
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Fax | 941-408-8446
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Provider Business Mailing Address
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Address Line | 2165 TAMIAMI TRL S
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City | VENICE
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State | FL
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Zip | 34293-5034
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Country | US
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Telephone | 941-493-8787
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Fax | 941-408-8446
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Authorized Official
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Title or Position | RECEPTIONIST
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Name | MS. JANE ELLEN BARTON
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Credential |
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Telephone | 941-493-8787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OP0002949
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License Number State | FL
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