Provider Demographics
NPI:1932394798
Name:BROADWATER, SHERRI MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:SHERRI
Middle Name:MARIE
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHERRI
Other - Middle Name:MARIE
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3622 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30337-2721
Mailing Address - Country:US
Mailing Address - Phone:404-458-0382
Mailing Address - Fax:678-335-2480
Practice Address - Street 1:3622 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30337-2721
Practice Address - Country:US
Practice Address - Phone:404-458-0382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM76332084P0804X
GA679422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194238504Medicaid
TX8L25532Medicare PIN