Provider Demographics
NPI:1215011218
Name:BROADBENT, BRYAN KENT (DPM)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KENT
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E 30TH ST BLDG D-101
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8991
Mailing Address - Country:US
Mailing Address - Phone:505-327-1400
Mailing Address - Fax:505-564-3202
Practice Address - Street 1:2300 E 30TH ST BLDG D-101
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8991
Practice Address - Country:US
Practice Address - Phone:505-327-1400
Practice Address - Fax:505-564-3202
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPOD417213ES0131X
ORDP 00375213ES0131X
COPOD.0000831213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10432353Medicaid