Basic Information
| Provider Information | |||||||||
| NPI: | 1205256047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROANE | ||||||||
| FirstName: | BRANDON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 221 W. COLORADO BLVD., PAV. II, STE. 532 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752082363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149439911 | ||||||||
| FaxNumber: | 2149468339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2014 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 37073 | AL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VX0201X | T3175 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 428271702 | 05 | TX | MEDICAID | 428271703 | 05 | TX | MEDICAID |