Provider Demographics
NPI:1447203823
Name:BROUGH, JONATHAN REEVES (MD)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:REEVES
Last Name:BROUGH
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 1:8160 WALNUT HILL LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4339
Mailing Address - Country:US
Mailing Address - Phone:214-363-4421
Mailing Address - Fax:214-987-1657
Practice Address - Street 1:8160 WALNUT HILL LN
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4339
Practice Address - Country:US
Practice Address - Phone:214-363-4421
Practice Address - Fax:214-987-1657
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7927174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH7927OtherSTATE LICENSE
TX81590YOtherBLUE CROSS/BLUE SHIELD
TX81590YOtherBLUE CROSS/BLUE SHIELD
TXH7927OtherSTATE LICENSE