Provider Demographics
NPI:1619035011
Name:BROD, JENNIFER S (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:S
Last Name:BROD
Suffix:
Gender:F
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:PO BOX 6946
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-0946
Mailing Address - Country:US
Mailing Address - Phone:610-372-9222
Mailing Address - Fax:610-372-0232
Practice Address - Street 1:655 WALNUT ST
Practice Address - Street 2:
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1242
Practice Address - Country:US
Practice Address - Phone:610-372-9222
Practice Address - Fax:610-372-0232
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042286E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001227073Medicaid
PA001227073Medicaid