Provider Demographics
NPI:1386710184
Name:BROUGHTON, NANAKO (MD)
Entity type:Individual
Prefix:DR
First Name:NANAKO
Middle Name:
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:11900 ATLANTIC BLVD # 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-2920
Practice Address - Country:US
Practice Address - Phone:904-839-1037
Practice Address - Fax:904-656-7273
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232003207R00000X
FLME111608207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010699500Medicaid
GA003155018AMedicaid
FLHS574ZMedicare PIN