Provider Demographics
NPI:1164517009
Name:BROMBERG, MARK B (MD,PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:BROMBERG
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 1:2782 ST MARYS WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2040
Mailing Address - Country:US
Mailing Address - Phone:801-585-5885
Mailing Address - Fax:801-585-2054
Practice Address - Street 1:30 N 1900 E SOM # 3R210
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-585-5885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8340A2084N0400X
UT274745-12052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTA76082Medicare UPIN
UT000011198Medicare ID - Type Unspecified