Provider Demographics
NPI:1871609453
Name:BRODEUR, CHRISTIAN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:EDWARD
Last Name:BRODEUR
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:PO BOX 3262
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-3262
Mailing Address - Country:US
Mailing Address - Phone:417-885-3888
Mailing Address - Fax:417-881-7268
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-269-6170
Practice Address - Fax:417-269-6992
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT20040164092085R0202X
MO20070295962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207057605Medicaid
MO152360131Medicare UPIN