Provider Demographics
NPI:1467457697
Name:BRODERICK, ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BRODERICK
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 1:23 MANHATTAN SQUARE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666
Mailing Address - Country:US
Mailing Address - Phone:757-595-0358
Mailing Address - Fax:757-595-6745
Practice Address - Street 1:23 MANHATTAN SQUARE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666
Practice Address - Country:US
Practice Address - Phone:757-595-0358
Practice Address - Fax:757-595-6745
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6716962Medicaid
VA6716962Medicaid