Healthcare Provider Details

I. General information

NPI: 1558780205
Provider Name (Legal Business Name): BRENT BJORNSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9827 N 95TH ST STE 105
SCOTTSDALE AZ
85258
US

IV. Provider business mailing address

9827 N 95TH ST STE 105
SCOTTSDALE AZ
85258-4591
US

V. Phone/Fax

Practice location:
  • Phone: 480-860-8488
  • Fax:
Mailing address:
  • Phone: 480-860-8488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number56068
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56068
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR3476
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: