MEDICARE: EKATERINA ALEXIS BROOUN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1326920711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EKATERINA ALEXIS BROOUN MD

Provider Business Mailing Address
First Line	:	27 S MARIO CAPECCHI DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84112-5888
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	134 K ST APT 3
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-5503
Country	:	US
Telephone Number	:	858-395-1747
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2025
Last Update Date	:	07/24/2025

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