Individual
KELLY CLARK BRODERICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
100 S SAN MATEO DR, SAN MATEO, CA 94401-3805
(650) 696-4515
(650) 696-4626
Mailing address
PO BOX 6102, NOVATO, CA 94948-6102
(415) 884-3418
(415) 883-3406
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
G78759
CA
2085U0001X
Diagnostic Ultrasound Physician
G78759
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00G787590
BLUE CROSS
CA
05
—
00G787590
—
CA
01
—
300121755
RAILROAD MEDICARE
CA
01
—
300121792
RAILROAD MEDICARE
CA
Enumeration date
05/24/2006
Last updated
09/23/2020
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