Provider Demographics
NPI:1679701197
Name:BLACKHAM, BRADY CADE (DO)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:CADE
Last Name:BLACKHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3321
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:95 EAST CENTER STREET
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:UT
Practice Address - Zip Code:84634
Practice Address - Country:US
Practice Address - Phone:435-528-7227
Practice Address - Fax:435-528-2175
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDMR-1062207Q00000X
UT8334270-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine