Provider Demographics
NPI:1659418267
Name:ELIASON, BENJAMIN RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:RAY
Last Name:ELIASON
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 1:10471 S ALEXANDER PARK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-3121
Mailing Address - Country:US
Mailing Address - Phone:541-678-3697
Mailing Address - Fax:
Practice Address - Street 1:1654 W REUNION AVE STE 10B
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4676
Practice Address - Country:US
Practice Address - Phone:801-349-2480
Practice Address - Fax:801-363-4885
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10366261-89052084P0800X
MN755892084P0800X
ORMD125756261Q00000X, 2084P0800X
UT10366261-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI27119Medicare UPIN