Provider Demographics
NPI:1669829545
Name:PIERSON, BENJAMIN (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:PIERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JARRETT WHITE RD
Mailing Address - Street 2:TRIPLER ARMY MEDICAL CENTER
Mailing Address - City:TRIPLER ARMY MEDICAL CENTER
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTER ST
Practice Address - Street 2:
Practice Address - City:FORT DETRICK
Practice Address - State:MD
Practice Address - Zip Code:21702-9211
Practice Address - Country:US
Practice Address - Phone:301-619-4637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI51010235962083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN