Healthcare Provider Details

I. General information

NPI: 1366575813
Provider Name (Legal Business Name): GERALD LEWIS BRODY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11716 ENTERPRISE DR
AUBURN CA
95603-3732
US

IV. Provider business mailing address

2052 OXBOW CT
MEADOW VISTA CA
95722-9415
US

V. Phone/Fax

Practice location:
  • Phone: 530-889-6700
  • Fax: 530-886-5415
Mailing address:
  • Phone: 530-878-7478
  • Fax: 530-878-2558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA018113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: