Basic Information
| Provider Information | |||||||||
| NPI: | 1609821891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6102 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949486102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158843418 | ||||||||
| FaxNumber: | 4158833406 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S SAN MATEO DR | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944013805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6506964515 | ||||||||
| FaxNumber: | 6506964626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | G78759 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | G78759 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G787590 | 05 | CA | MEDICAID | 300121792 | 01 | CA | RAILROAD MEDICARE | OTHER | 00G787590 | 01 | CA | BLUE CROSS | OTHER | 300121755 | 01 | CA | RAILROAD MEDICARE | OTHER |