Provider Demographics
NPI:1104952373
Name:NORDSTROM, BENJAMIN R (MD, PHD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:R
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756
Mailing Address - Country:US
Mailing Address - Phone:603-650-5574
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756
Practice Address - Country:US
Practice Address - Phone:603-650-5574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2260272084P0800X, 2084P0802X
PAMD4328012084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry