Provider Demographics
NPI:1043455025
Name:LEWIS, BENJAMIN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3709
Mailing Address - Country:US
Mailing Address - Phone:801-673-9482
Mailing Address - Fax:
Practice Address - Street 1:1409 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3709
Practice Address - Country:US
Practice Address - Phone:801-673-9482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT7471417-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program