Provider Demographics
NPI:1043507205
Name:BROADBENT, TALMAGE JAY (MD,PHD)
Entity Type:Individual
Prefix:MR
First Name:TALMAGE
Middle Name:JAY
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 S. SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1325
Mailing Address - Country:US
Mailing Address - Phone:509-279-2176
Mailing Address - Fax:509-279-2941
Practice Address - Street 1:626 S. SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1325
Practice Address - Country:US
Practice Address - Phone:509-279-2176
Practice Address - Fax:509-279-2941
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58899207W00000X
WAMD60704061207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2079499Medicaid