Provider Demographics
NPI:1780663294
Name:BROMAN, KATHERINE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:MARIE
Last Name:BROMAN
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 1:410 BENEDICTA AVE
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2005
Mailing Address - Country:US
Mailing Address - Phone:719-846-9213
Mailing Address - Fax:719-846-2752
Practice Address - Street 1:400 BENEDICTA AVE
Practice Address - Street 2:STE A
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2089
Practice Address - Country:US
Practice Address - Phone:719-846-2206
Practice Address - Fax:719-846-7823
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27075207Q00000X
CODR.0056414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0265223Medicaid
IA54422OtherBCBS GROUP NUMBER
IA27075OtherSTATE LICENSE NUMBER
IA54447OtherBCBS INDIVIDUAL NUMBER
IA21950OtherMIDLANDS CHOICE ID
IA2107748Medicaid
IA611412873OtherEIN
IA21950OtherMIDLANDS CHOICE ID
IA54422OtherBCBS GROUP NUMBER
IAE57545Medicare UPIN