Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | K4001 | TX |
N | 207VG0400X | Gynecologist | K4001 | TX |
N | 207VM0101X | Gynecologist - Maternal & Fetal Medicine | K4001 | TX |
N | 207VX0000X | Obstetrician | K4001 | TX |
NPI | 1457357279 |
---|---|
Provider Name | Jenifer Arlene Broderick-Thomas |
First Address | Dallas, TX 75266-0046 |
Second Address | Plano, TX 75093-8103 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2005 |
Last Update Date | 15/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8M0810 | BCBS (01) | TX |
G58576 | (02) |