Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0122X | Plastic and Reconstructive Surgery | R6354 | TX |
NPI | 1295034940 |
---|---|
Provider Name | Dr. Justin Michael Broyles |
First Address | Houston, TX 77210-4439 |
Second Address | Houston, TX 77030-4009 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2011 |
Last Update Date | 02/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
387008101 | (05) | TX |
387008102 | (05) | TX |
8JQ419 | BCBS (01) | TX |