Provider Demographics
NPI:1457606360
Name:BRODBAKER, ELLIOTT JASON BARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:JASON BARRY
Last Name:BRODBAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:670 W CAMPBELL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3358
Mailing Address - Country:US
Mailing Address - Phone:469-998-3554
Mailing Address - Fax:
Practice Address - Street 1:670 W CAMPBELL RD STE 100
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3358
Practice Address - Country:US
Practice Address - Phone:469-998-3554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4368207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology