Healthcare Provider Details

I. General information

NPI: 1750383097
Provider Name (Legal Business Name): BRENT RAY BURDETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5929 FASHION POINT DR STE 101
SOUTH OGDEN UT
84403-4672
US

IV. Provider business mailing address

5929 FASHION POINT DR STE 101
SOUTH OGDEN UT
84403-4672
US

V. Phone/Fax

Practice location:
  • Phone: 801-476-0052
  • Fax: 801-476-0064
Mailing address:
  • Phone: 801-476-0052
  • Fax: 801-476-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number75-158533-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: