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General NPI Number Information
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NPI Number | 1366646416
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Entity Type | Individual
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Provider Name | DALLAS BROADWAY M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/13/2007
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Last Update Date | 05/14/2026
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Provider Practice Location Address
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Address Line | 622 W 168TH ST, NEW YORK, NY 10032
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City | NEW YORK
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State | NY
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Zip | 10032
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Country | US
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Telephone | 877-426-5637
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Fax |
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Provider Business Mailing Address
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Address Line | 1010 NW LOOP 410 STE 100B
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City | SAN ANTONIO
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State | TX
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Zip | 78213-2220
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Country | US
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Telephone | 210-465-7015
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Fax | 210-465-7014
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 25MA09187400
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 249640
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | P8223
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License Number State | TX
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