Provider Demographics
NPI:1992791826
Name:BRODY, GORDON S (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:S
Last Name:BRODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W INTERSTATE 20
Mailing Address - Street 2:SUITE G22
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5870
Mailing Address - Country:US
Mailing Address - Phone:817-784-8268
Mailing Address - Fax:817-276-1861
Practice Address - Street 1:811 W INTERSTATE 20
Practice Address - Street 2:SUITE G22
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-5870
Practice Address - Country:US
Practice Address - Phone:817-784-8268
Practice Address - Fax:817-276-1861
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7839208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122740707Medicaid
TX122740704Medicaid
TX122740705Medicaid
TX122740703Medicaid
TX122740706OtherMEDICAID OTHER
TX83Z790Medicare PIN
TX122740703Medicaid
TXC13789Medicare UPIN
TX122740705Medicaid