MEDICARE: DR. JOHN H BROADDUS OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OEG001548	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	57761	OTHER		AETNA PROVIDER #

General Provider Information

NPI Number	:	1477551133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN H BROADDUS OD

Provider Business Mailing Address
First Line	:	471 PARK CITY CTR
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17601-2711
Country	:	US
Telephone Number	:	717-393-4042
Fax Number	:

Provider Business Practice Location Address
First Line	:	471 PARK CITY CTR
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17601-2711
Country	:	US
Telephone Number	:	717-393-4042
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	04/10/2022

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