Provider Demographics
NPI:1346264132
Name:BRODSKY, CHARLES S (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:BRODSKY
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 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-824-3200
Mailing Address - Fax:
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-824-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0649207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G28472Medicare UPIN
84084FMedicare ID - Type Unspecified