Provider Demographics
NPI:1720129992
Name:BROOME, CHARLES BRANDON (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRANDON
Last Name:BROOME
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 47052
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78265-7052
Mailing Address - Country:US
Mailing Address - Phone:210-614-5100
Mailing Address - Fax:210-614-5103
Practice Address - Street 1:225 E SONTERRA BLVD STE 220
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3992
Practice Address - Country:US
Practice Address - Phone:210-614-5100
Practice Address - Fax:210-614-5103
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7078207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX295644YM2FMedicare PIN
SCAA73737951Medicare PIN