Provider Demographics
NPI:1164002465
Name:JAMESON, BRODERICK D (MD)
Entity type:Individual
Prefix:
First Name:BRODERICK
Middle Name:D
Last Name:JAMESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRODY
Other - Middle Name:
Other - Last Name:JAMESON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 980257
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0257
Mailing Address - Country:US
Mailing Address - Phone:804-828-9783
Mailing Address - Fax:
Practice Address - Street 1:1000 E BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1930
Practice Address - Country:US
Practice Address - Phone:804-827-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-11
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101282384208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program