Provider Demographics
NPI:1235792375
Name:JOHNSON, BENJAMIN TANKEVER
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:TANKEVER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13001 E 17TH PL BLDG 500
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2570
Mailing Address - Country:US
Mailing Address - Phone:303-724-6019
Mailing Address - Fax:
Practice Address - Street 1:2600 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5511
Practice Address - Country:US
Practice Address - Phone:307-633-7370
Practice Address - Fax:307-637-7202
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY16324A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry