Provider Demographics
NPI:1639188394
Name:BROADDRICK, KEVIN STANLEY (DPM)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:STANLEY
Last Name:BROADDRICK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3149 E HAZELTINE WAY
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-9066
Mailing Address - Country:US
Mailing Address - Phone:414-702-0954
Mailing Address - Fax:
Practice Address - Street 1:6739 W CACTUS RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5311
Practice Address - Country:US
Practice Address - Phone:833-242-0100
Practice Address - Fax:602-805-4745
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPOD-000814213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43218700Medicaid