Basic Information
| Provider Information | |||||||||
| NPI: | 1639188394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROADDRICK | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | STANLEY | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7373 E. US HIGHWAY 60, #378 | ||||||||
| Address2: | |||||||||
| City: | GOLD CANYON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147020954 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14780 W. MOUNTAIN VIEW BLVD. | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853747280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233747774 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 07/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 657 | WI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 43218700 | 05 | WI | MEDICAID |