Provider Demographics
NPI:1730594029
Name:BROSE, TEODORA
Entity type:Individual
Prefix:
First Name:TEODORA
Middle Name:
Last Name:BROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 JONES ST
Mailing Address - Street 2:
Mailing Address - City:APPOMATTOX
Mailing Address - State:VA
Mailing Address - Zip Code:24522-9830
Mailing Address - Country:US
Mailing Address - Phone:434-352-8235
Mailing Address - Fax:434-352-5532
Practice Address - Street 1:131 JONES ST
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522
Practice Address - Country:US
Practice Address - Phone:434-352-8235
Practice Address - Fax:434-352-5532
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101261264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA207Q00000XOtherFAMILY MEDICINE