Provider Demographics
NPI:1437225612
Name:BROADBENT, DAVID HARRISON (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:HARRISON
Last Name:BROADBENT
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 1:1355 N UNIVERSITY AVE # 130
Mailing Address - Street 2:SUITE # 130
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-373-4649
Mailing Address - Fax:801-373-7555
Practice Address - Street 1:1355 N UNIVERSITY AVE # 130
Practice Address - Street 2:SUITE # 130
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-373-4649
Practice Address - Fax:801-373-7555
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT751582011205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB9150450OtherDEA
UT000001017Medicare ID - Type Unspecified
D99978Medicare UPIN