Provider Demographics
NPI:1134117096
Name:BRODNAX, JEAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:R
Last Name:BRODNAX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 GROSSMAN DR
Mailing Address - Street 2:PEDIATRICS DEPT
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-4997
Mailing Address - Country:US
Mailing Address - Phone:781-849-2302
Mailing Address - Fax:
Practice Address - Street 1:111 GROSSMAN DR
Practice Address - Street 2:PEDIATRICS DEPT
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4997
Practice Address - Country:US
Practice Address - Phone:781-849-2302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA49913208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3191320Medicaid
MA3191320Medicaid