Provider Demographics
NPI:1437422995
Name:ROBERTSON, BRENT FARR (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:FARR
Last Name:ROBERTSON
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 1:1321 E SOUTH TEMPLE
Mailing Address - Street 2:5
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1830
Mailing Address - Country:US
Mailing Address - Phone:801-643-5809
Mailing Address - Fax:
Practice Address - Street 1:1321 E SOUTH TEMPLE
Practice Address - Street 2:5
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1830
Practice Address - Country:US
Practice Address - Phone:801-643-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT168260-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC46726Medicare UPIN