Provider Demographics
NPI:1295711018
Name:BROSHEARS, JOHN R (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:BROSHEARS
Suffix:
Gender:M
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:P.O. BOX 15079
Mailing Address - Street 2:BRADENTON PATHOLOGY, P.A.
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34280
Mailing Address - Country:US
Mailing Address - Phone:941-798-6177
Mailing Address - Fax:941-798-6168
Practice Address - Street 1:2020 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4604
Practice Address - Country:US
Practice Address - Phone:941-798-6177
Practice Address - Fax:941-798-6168
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029754A207ZP0102X
FLME0037595207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200297250AMedicaid
IN000000092720OtherANTHEM
IN000000009158OtherMPLAN
IN000000092720OtherANTHEM
679170CCMedicare ID - Type Unspecified
F00113Medicare UPIN