Individual
KELLY CLARK BRODERICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
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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