Healthcare Provider Details

I. General information

NPI: 1215011218
Provider Name (Legal Business Name): BRYAN KENT BROADBENT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST BLDG D-101
FARMINGTON NM
87401-8991
US

IV. Provider business mailing address

2300 E 30TH ST BLDG D-101
FARMINGTON NM
87401-8991
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-1400
  • Fax: 505-564-3202
Mailing address:
  • Phone: 505-327-1400
  • Fax: 505-564-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPOD417
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDP 00375
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPOD.0000831
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: