Basic Information
| Provider Information | |||||||||
| NPI: | 1285645002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., M.ED. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 PARADISE RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953513104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095584000 | ||||||||
| FaxNumber: | 2095585036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G63629 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.