Provider Demographics
NPI:1902600562
Name:BROADSTOCK, SVETLANA (LDO)
Entity type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:BROADSTOCK
Suffix:
Gender:
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W HAPPY VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-3701
Mailing Address - Country:US
Mailing Address - Phone:623-780-5719
Mailing Address - Fax:
Practice Address - Street 1:2501 W HAPPY VALLEY RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-3701
Practice Address - Country:US
Practice Address - Phone:623-780-5719
Practice Address - Fax:623-780-5721
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2471I156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician