Provider Demographics
NPI:1124724463
Name:BROADWAY, CASSANDRA
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-3806
Mailing Address - Country:US
Mailing Address - Phone:510-807-4390
Mailing Address - Fax:
Practice Address - Street 1:2280 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1321
Practice Address - Country:US
Practice Address - Phone:510-807-4390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service