Healthcare Provider Details

I. General information

NPI: 1124482815
Provider Name (Legal Business Name): JARED BROUGHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 STATE ST
MEDFORD OR
97504-8458
US

IV. Provider business mailing address

2900 STATE ST
MEDFORD OR
97504-8458
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-1672
  • Fax:
Mailing address:
  • Phone: 541-779-1672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD222114
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberDR.0071013
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: