Healthcare Provider Details

I. General information

NPI: 1235134859
Provider Name (Legal Business Name): BERNETTA E BROUGHTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N 51ST AVE STE 4
PHOENIX AZ
85031-1237
US

IV. Provider business mailing address

4700 N 51ST AVE STE 4
PHOENIX AZ
85031-1237
US

V. Phone/Fax

Practice location:
  • Phone: 623-846-7575
  • Fax: 623-247-6386
Mailing address:
  • Phone: 623-846-7575
  • Fax: 623-247-6386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15087
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number15087
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: