Provider Demographics
NPI:1699901231
Name:BROADBENT, DANIEL WILFORD (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:WILFORD
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:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-397-6080
Mailing Address - Fax:801-397-6081
Practice Address - Street 1:991 SHEPARD LN
Practice Address - Street 2:STE 200
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2972
Practice Address - Country:US
Practice Address - Phone:801-397-6080
Practice Address - Fax:801-397-6081
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9314408-1205207Q00000X
WY9066A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000091603Medicare PIN