Provider Demographics
NPI:1225129158
Name:WATSON, BRENT THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:THOMAS
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 WESTBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1586
Mailing Address - Country:US
Mailing Address - Phone:801-589-3177
Mailing Address - Fax:801-475-9499
Practice Address - Street 1:2132 N 1700 W STE 230
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7060
Practice Address - Country:US
Practice Address - Phone:801-773-3900
Practice Address - Fax:801-773-3900
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT187506-1205207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH66239Medicare UPIN
UT005750501Medicare ID - Type Unspecified