Basic Information
Provider Information | |||||||||
NPI: | 1053491183 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEBENHAM | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3340 NORTH CENTER ST | ||||||||
Address2: | #800 | ||||||||
City: | LEHI | ||||||||
State: | UT | ||||||||
PostalCode: | 840437406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019901911 | ||||||||
FaxNumber: | 8019901912 | ||||||||
Practice Location | |||||||||
Address1: | 1380 EAST MEDICAL CENTER DRIVE | ||||||||
Address2: | DIXIE REGIONAL MEDICAL CENTER | ||||||||
City: | ST. GEORGE | ||||||||
State: | UT | ||||||||
PostalCode: | 84790 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4352511000 | ||||||||
FaxNumber: | 8019901912 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2006 | ||||||||
LastUpdateDate: | 10/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 184722-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 2090168 | 01 | UT | UNITED HEALTHCARE | OTHER | 870545614DEB | 01 | UT | EDUCATORS MUTUAL | OTHER | QM0000075886 | 01 | UT | ALTIUS | OTHER | 118909300 | 05 | WY |   | MEDICAID | 24592 | 01 | UT | DESERET MUTUAL | OTHER | 71443 | 01 | UT | PEHP | OTHER | 002088120 | 05 | NV |   | MEDICAID | 066812002 | 05 | AZ |   | MEDICAID | 806392300 | 05 | ID |   | MEDICAID | 107005903103 | 01 | UT | IHC | OTHER | 52858 | 01 | UT | HEALTHY U | OTHER | PRA02634 | 01 | UT | MOLINA | OTHER |