Provider Demographics
NPI:1750344719
Name:BROUDO, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BROUDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1100 SW 57TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-5129
Mailing Address - Country:US
Mailing Address - Phone:305-262-6484
Mailing Address - Fax:305-263-6370
Practice Address - Street 1:1100 SW 57TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:WEST MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-5129
Practice Address - Country:US
Practice Address - Phone:305-262-6484
Practice Address - Fax:305-263-6370
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME74337208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G76876Medicare UPIN