Provider Demographics
NPI:1962691766
Name:BROSELOW, ROBERT JOEL (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOEL
Last Name:BROSELOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 19TH ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1003
Mailing Address - Country:US
Mailing Address - Phone:806-795-9020
Mailing Address - Fax:806-795-4726
Practice Address - Street 1:4009 19TH ST
Practice Address - Street 2:SUITE E
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1003
Practice Address - Country:US
Practice Address - Phone:806-795-9020
Practice Address - Fax:806-795-4726
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9089207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123600206Medicaid
TX123600206Medicaid
TX8A9963Medicare PIN