Provider Demographics
NPI:1457357279
Name:BRODERICK-THOMAS, JENIFER ARLENE (MD)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:ARLENE
Last Name:BRODERICK-THOMAS
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 660046
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0046
Mailing Address - Country:US
Mailing Address - Phone:214-369-8555
Mailing Address - Fax:
Practice Address - Street 1:6300 W PARKER RD
Practice Address - Street 2:STE 325
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8103
Practice Address - Country:US
Practice Address - Phone:972-981-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4001207V00000X, 207VG0400X, 207VM0101X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8M0810OtherBCBS
G58576Medicare UPIN
TX8F2725Medicare PIN