Provider Demographics
NPI:1265538045
Name:JOHN H BROADDUS
Entity type:Organization
Organization Name:JOHN H BROADDUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HALE
Authorized Official - Last Name:BROADDUS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:717-393-4042
Mailing Address - Street 1:1158 PARK CITY CTR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2726
Mailing Address - Country:US
Mailing Address - Phone:717-393-4042
Mailing Address - Fax:
Practice Address - Street 1:1158 PARK CITY CTR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2726
Practice Address - Country:US
Practice Address - Phone:717-393-4042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001548152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty