MEDICARE: DR. JEAN R BRODNAX M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	49913	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134117096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEAN R BRODNAX M.D.

Provider Business Mailing Address
First Line	:	111 GROSSMAN DR
Second Line	:	PEDIATRICS DEPT
City	:	BRAINTREE
State	:	MA
Zip	:	02184-4997
Country	:	US
Telephone Number	:	781-849-2302
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 GROSSMAN DR
Second Line	:	PEDIATRICS DEPT
City	:	BRAINTREE
State	:	MA
Zip	:	02184-4997
Country	:	US
Telephone Number	:	781-849-2302
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	01/07/2021

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