Healthcare Provider Details

I. General information

NPI: 1619362779
Provider Name (Legal Business Name): JOSHUA BRIAN BRADSHAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2015
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 RENAISSANCE TOWNE DR STE 310
BOUNTIFUL UT
84010-7671
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-295-5581
  • Fax: 801-295-9253
Mailing address:
  • Phone: 801-475-3500
  • Fax: 801-475-3494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number117035791205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: