Provider Demographics
NPI:1306829569
Name:BROADHEAD, JEFFREY L (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:BROADHEAD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3556 W 9800 S
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-3211
Mailing Address - Country:US
Mailing Address - Phone:801-253-6590
Mailing Address - Fax:801-253-6591
Practice Address - Street 1:3556 W 9800 S
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3211
Practice Address - Country:US
Practice Address - Phone:801-253-6590
Practice Address - Fax:801-253-6591
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4826018-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU88209Medicare UPIN