Provider Demographics
NPI:1083611669
Name:BEN-JACOB, ALI (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:BEN-JACOB
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 1:1281 NORTH 600 EAST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2443
Mailing Address - Country:US
Mailing Address - Phone:435-752-5999
Mailing Address - Fax:435-752-5551
Practice Address - Street 1:1281 NORTH 600 EAST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2443
Practice Address - Country:US
Practice Address - Phone:435-752-5999
Practice Address - Fax:435-752-5551
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT292373-1205207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1083611669OtherNATIONAL PROVIDER IDENTIFIER
UT005722201Medicare PIN
UTF73147Medicare UPIN