Provider Demographics
NPI:1669417580
Name:BRODE, DONALD R (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:R
Last Name:BRODE
Suffix:
Gender:M
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 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:3828 S 1ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7048
Practice Address - Country:US
Practice Address - Phone:512-443-1311
Practice Address - Fax:512-448-8264
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044570201Medicaid
TX044570202Medicaid
H25018Medicare UPIN
TX8K2229Medicare PIN
TX8A6005Medicare PIN
TX080165861Medicare PIN
TX8600J3Medicare PIN