Healthcare Provider Details

I. General information

NPI: 1366646416
Provider Name (Legal Business Name): DALLAS BROADWAY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST, NEW YORK, NY 10032
NEW YORK NY
10032
US

IV. Provider business mailing address

1010 NW LOOP 410 STE 100B
SAN ANTONIO TX
78213-2220
US

V. Phone/Fax

Practice location:
  • Phone: 877-426-5637
  • Fax:
Mailing address:
  • Phone: 210-465-7015
  • Fax: 210-465-7014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number25MA09187400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number249640
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number249640
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberP8223
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: