Provider Demographics
NPI:1144334756
Name:WATSON, BENJAMIN (CPED)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5728 S 1475 E
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4833
Mailing Address - Country:US
Mailing Address - Phone:801-710-7347
Mailing Address - Fax:801-479-4577
Practice Address - Street 1:5728 S 1475 E
Practice Address - Street 2:SUITE 102
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4833
Practice Address - Country:US
Practice Address - Phone:801-710-7347
Practice Address - Fax:801-479-4577
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT270031488001Medicaid
UT270031488001Medicaid