Provider Demographics
NPI:1083063077
Name:WATANABE, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WATANABE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 LA CALMA DR STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-3825
Mailing Address - Country:US
Mailing Address - Phone:888-800-8237
Mailing Address - Fax:
Practice Address - Street 1:1500 RED RIVER ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701
Practice Address - Country:US
Practice Address - Phone:512-324-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR8681207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine