Basic Information
| Provider Information | |||||||||
| NPI: | 1710932009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODSKY | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | LOUIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4225 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880661 | ||||||||
| FaxNumber: | 7632872310 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880661 | ||||||||
| FaxNumber: | 7633024345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 18799 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0265003 | 01 | MN | PREFERRED ONE | OTHER | 0500353 | 01 | MN | MEDICA | OTHER | 183070800 | 05 | MN | MEDICAID | 30204400 | 05 | WI | MEDICAID | 02062BR | 01 | MN | BCBS OF MN | OTHER | 22782 | 01 | MN | AMERICA'S PPO | OTHER | 0507376 | 05 | IA | MEDICAID | HP12967 | 01 | MN | HEALTHPARTNERS | OTHER | 100279C029 | 01 | MN | UCARE | OTHER | 130004298 | 01 | MN | RAILROAD MEDICARE | OTHER |