Healthcare Provider Details

I. General information

NPI: 1265467567
Provider Name (Legal Business Name): LEE S BROADBENT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 E 1400 N SUITE D
LOGAN UT
84341
US

IV. Provider business mailing address

550 E 1400 N SUITE D
LOGAN UT
84341
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-7122
  • Fax: 435-755-9579
Mailing address:
  • Phone: 435-752-7122
  • Fax: 435-755-9579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number731556181205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: