Provider Demographics
NPI:1366575813
Name:BRODY, GERALD LEWIS (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:LEWIS
Last Name:BRODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2052 OXBOW CT
Mailing Address - Street 2:
Mailing Address - City:MEADOW VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95722-9415
Mailing Address - Country:US
Mailing Address - Phone:530-878-7478
Mailing Address - Fax:530-878-2558
Practice Address - Street 1:11716 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-3732
Practice Address - Country:US
Practice Address - Phone:530-889-6700
Practice Address - Fax:530-886-5415
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0181132084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA18113OtherMEDICAL LICENSE
AB0297855OtherDOJ-DEA
CAF08840Medicare UPIN