Healthcare Provider Details

I. General information

NPI: 1073993283
Provider Name (Legal Business Name): COLTEN DIRK BRACKEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 EAST MAIN STREET
ENTERPRISE UT
84725
US

IV. Provider business mailing address

1055 N 500 W
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 435-878-5711
  • Fax: 435-878-5712
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-377-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9832788-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: