Provider Demographics
NPI:1629008750
Name:BENCH, CLYDE JARDINE (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:JARDINE
Last Name:BENCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CLYDE
Other - Middle Name:J
Other - Last Name:BENCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-535-8163
Mailing Address - Fax:801-355-4011
Practice Address - Street 1:333 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2310
Practice Address - Country:US
Practice Address - Phone:801-535-8163
Practice Address - Fax:801-355-4011
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT151073-1205207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D99458Medicare UPIN