Provider Demographics
NPI:1114115664
Name:BROADHURST, JEREMY (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BROADHURST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-357-7930
Mailing Address - Fax:
Practice Address - Street 1:190 S HIGHWAY 165
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9512
Practice Address - Country:US
Practice Address - Phone:435-755-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6681706-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000064363Medicare PIN