Healthcare Provider Details

I. General information

NPI: 1417998022
Provider Name (Legal Business Name): BRUCE O BURNHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S MEDICAL DR
MT PLEASANT UT
84647-2222
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 435-462-2441
  • Fax: 435-462-2609
Mailing address:
  • Phone: 801-357-7475
  • Fax: 801-357-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1607521205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: