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General NPI Number Information
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NPI Number | 1215011218
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Entity Type | Individual
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Provider Name | BRYAN KENT BROADBENT DPM
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Gender | Male
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 10/01/2019
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Provider Practice Location Address
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Address Line | 2300 E 30TH ST BLDG D-101
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City | FARMINGTON
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State | NM
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Zip | 87401-8991
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Country | US
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Telephone | 505-327-1400
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Fax | 505-564-3202
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Provider Business Mailing Address
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Address Line | 2300 E 30TH ST BLDG D-101
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City | FARMINGTON
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State | NM
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Zip | 87401-8991
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Country | US
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Telephone | 505-327-1400
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Fax | 505-564-3202
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | POD417
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | DP 00375
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | POD.0000831
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License Number State | CO
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