Healthcare Provider Details

I. General information

NPI: 1134117096
Provider Name (Legal Business Name): JEAN R BRODNAX M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 GROSSMAN DR PEDIATRICS DEPT
BRAINTREE MA
02184-4997
US

IV. Provider business mailing address

111 GROSSMAN DR PEDIATRICS DEPT
BRAINTREE MA
02184-4997
US

V. Phone/Fax

Practice location:
  • Phone: 781-849-2302
  • Fax:
Mailing address:
  • Phone: 781-849-2302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49913
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: