Provider Demographics
NPI:1316942519
Name:BRODER, STANFORD R (MD)
Entity type:Individual
Prefix:
First Name:STANFORD
Middle Name:R
Last Name:BRODER
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 1:51-53 KENOSIA AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810
Mailing Address - Country:US
Mailing Address - Phone:203-748-0330
Mailing Address - Fax:203-731-3273
Practice Address - Street 1:51-53 KENOSIA AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-748-0330
Practice Address - Fax:203-731-3273
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037497208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001374975Medicaid
CTG12321Medicare UPIN
CT001374975Medicaid