Provider Demographics
NPI:1609862127
Name:BRODY, JENNIFER DIANE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:BRODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DIANE
Other - Last Name:HOLMBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1139 E SONTERRA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4347
Mailing Address - Country:US
Mailing Address - Phone:210-499-0770
Mailing Address - Fax:210-499-0750
Practice Address - Street 1:1139 E SONTERRA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4347
Practice Address - Country:US
Practice Address - Phone:210-499-0770
Practice Address - Fax:210-499-0750
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2015-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1536207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1995102-02Medicaid
TXB163214Medicare PIN