Basic Information
Provider Information | |||||||||
NPI: | 1396731469 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENNION | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | GREEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2245 N 400 E | ||||||||
Address2: | STE 301 | ||||||||
City: | NORTH LOGAN | ||||||||
State: | UT | ||||||||
PostalCode: | 843411892 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357537880 | ||||||||
FaxNumber: | 4357535845 | ||||||||
Practice Location | |||||||||
Address1: | 2245 N 400 E | ||||||||
Address2: | STE 301 | ||||||||
City: | NORTH LOGAN | ||||||||
State: | UT | ||||||||
PostalCode: | 843411892 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357537880 | ||||||||
FaxNumber: | 4357535845 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2005 | ||||||||
LastUpdateDate: | 06/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0007X | 274201-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
ID | Type | State | Issuer | Description | BB4062876 | 01 | UT | DEA | OTHER | 7054 | 01 | ID | IDAHO BOARD OF PHARMACY | OTHER | 274201-9915 | 01 | UT | UTAH CONTROLLED SUBSTANCE | OTHER | M-6924 | 01 | ID | IDAHO STATE LICENSE | OTHER |