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General NPI Number Information
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NPI Number | 1255411419
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Entity Type | Individual
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Provider Name | BRYAN LEONARD BERGHOUT DPM
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Gender | Male
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 02/05/2024
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Provider Practice Location Address
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Address Line | 10821 19TH AVE SE
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City | EVERETT
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State | WA
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Zip | 98208-5103
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Country | US
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Telephone | 425-337-7000
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Fax | 425-338-2408
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Provider Business Mailing Address
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Address Line | 6405 S 3000 E STE 201
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City | SALT LAKE CITY
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State | UT
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Zip | 84121-6990
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Country | US
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Telephone | 801-266-3113
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Fax | 801-266-5633
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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 | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | PO00000813
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License Number State | WA
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