Provider Demographics
NPI:1154389591
Name:BROUGHTON, ROBERT E (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
Last Name:BROUGHTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1803
Mailing Address - Country:US
Mailing Address - Phone:434-791-4122
Mailing Address - Fax:434-791-4088
Practice Address - Street 1:705 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1803
Practice Address - Country:US
Practice Address - Phone:434-791-4122
Practice Address - Fax:434-791-4126
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051412208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010241596Medicaid
VA010241596Medicaid