Basic Information
| Provider Information | |||||||||
| NPI: | 1801833744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROBBEY | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11511 SHADOW CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775847298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134420000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1915 LAKEFRONT DR | ||||||||
| Address2: | |||||||||
| City: | MISSOURI CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774591651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819698860 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G0899 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 121542805 | 05 | TX | MEDICAID | 412069533 0001 | 01 | CIGNA PRV ID NUMBER | OTHER | 121542809 | 05 | TX | MEDICAID | 42069533001 | 01 | TRICARE PROV ID NUMBER | OTHER | BB1429148 | 01 | FEDERAL DEA NUMBER | OTHER | S0045716 | 01 | TX | STATE DPS NUMBER | OTHER | 00000034JV | 01 | TX | BCBS PROV. NUMBER | OTHER | 10018140 | 01 | VA | AMERIGROUP PROV ID NUMBER | OTHER | 3056377 | 01 | AETNA PROV NUMBER | OTHER | 1801833744 | 01 | NPI | OTHER | 236-282-0 | 01 | ECFMG NUMBER | OTHER | 48268 | 01 | MA | MASS BD OF REGISTRATION | OTHER | 0007929017 | 01 | AETNA PIN | OTHER | 121542810 | 05 | TX | MEDICAID | 31381 | 01 | AMERICAN BD OF PEDIATRICS | OTHER | 45D1007578 | 01 | CLIA CERT. OF WAIVER | OTHER | G0899 | 01 | TX | ST. BD OF MED EXAMINERS | OTHER | 121542806 | 05 | TX | MEDICAID | 121542811 | 05 | TX | MEDICAID | 236-282-0 | 01 | ECFMG | OTHER |