Provider Demographics
NPI:1235134859
Name:BROUGHTON, BERNETTA E (MD)
Entity Type:Individual
Prefix:
First Name:BERNETTA
Middle Name:E
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 N 51ST AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-1237
Mailing Address - Country:US
Mailing Address - Phone:623-846-7575
Mailing Address - Fax:623-247-6386
Practice Address - Street 1:4700 N 51ST AVE
Practice Address - Street 2:STE 4
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1237
Practice Address - Country:US
Practice Address - Phone:623-846-7575
Practice Address - Fax:623-247-6386
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15087208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0182590OtherBCBS
AZ1Z8746OtherHEALTHNET
AZ251794Medicaid
AZ770934OtherUNITED HEALTHCARE
AZ85031A006OtherTRICARE