Provider Demographics
NPI:1205675790
Name:BROADWAY, JOE EDWARD III (OD)
Entity type:Individual
Prefix:DR
First Name:JOE
Middle Name:EDWARD
Last Name:BROADWAY
Suffix:III
Gender:M
Credentials:OD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2355 N STATE HIGHWAY 360 APT 625
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-8716
Mailing Address - Country:US
Mailing Address - Phone:972-822-3148
Mailing Address - Fax:
Practice Address - Street 1:2355 N STATE HIGHWAY 360 APT 625
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-8716
Practice Address - Country:US
Practice Address - Phone:972-822-3148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11188152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist