Active NPI
Elliot Duane Broadhead, DPT
- Physical Therapist
- Sheppard Afb, TX
National Provider Identifier
1255996468
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 5817
- Practice address
- 527 5TH Ave #500
Sheppard Afb, TX 76311 - Phone
- (208) 828-4626
- NPI assigned
- May 2, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 5817 | ID | Primary |
Addresses
Primary practice location
527 5TH Ave #500
Sheppard Afb, TX 76311
Mailing address
1410 W Airbase Rd Apt 2
Mountain Home, ID 83647-3344
Phone (208) 730-7467
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5817 | ID | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1556755200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1694995200000",
"number": "1255996468",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1410 W AIRBASE RD APT 2",
"city": "MOUNTAIN HOME",
"state": "ID",
"postal_code": "836473344",
"telephone_number": "208-730-7467"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "527 5TH AVE #500",
"city": "SHEPPARD AFB",
"state": "TX",
"postal_code": "76311",
"telephone_number": "208-828-4626"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BROADHEAD",
"first_name": "ELLIOT",
"middle_name": "DUANE",
"credential": "DPT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-05-02",
"last_updated": "2023-09-18",
"certification_date": "2023-09-13",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "ID",
"license": "5817",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Sheppard Afb, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.