Provider Demographics
NPI:1568423564
Name:EARL, BRETT (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:EARL
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 1:458 N 500 W
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6948
Mailing Address - Country:US
Mailing Address - Phone:801-296-8060
Mailing Address - Fax:801-296-8050
Practice Address - Street 1:458 N 500 W
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6948
Practice Address - Country:US
Practice Address - Phone:801-296-8060
Practice Address - Fax:801-296-8050
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5110301-1205207PE0004X, 207P00000X
UT5110301208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4575Medicaid
UT005568327Medicare ID - Type Unspecified3460 PIONEER PKWY, WVC
UT005568530Medicare ID - Type Unspecified630 MEDICAL DR, BOUNTIFUL
UT005568622Medicare ID - Type Unspecified1050 E SOUTH TEMPLE, SLC
UT005567117Medicare ID - Type Unspecified1600 ANTELOPE DR, LAYTON
UTH27510Medicare UPIN
UT005568420Medicare ID - Type Unspecified3580 W 9000 S, W JORDAN
UT005567217Medicare ID - Type Unspecified5475 S 500 E, OGDEN