Provider Demographics
NPI:1689860850
Name:GORDON, BENJAMIN HOLLIS JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:HOLLIS JAMES
Last Name:GORDON
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 1:5444 S. GREEN ST.
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5632
Mailing Address - Country:US
Mailing Address - Phone:801-262-8120
Mailing Address - Fax:801-262-3897
Practice Address - Street 1:5444 S. GREEN ST.
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-5632
Practice Address - Country:US
Practice Address - Phone:801-262-8120
Practice Address - Fax:801-262-3897
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 600339672085R0202X
CAA1032902085R0202X
IDM-103692085R0202X
UT5763853-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID77798OtherBLUE CROSS OF IDAHO
ID000010171612OtherREGENCE BLUE SHIELD OF IDAHO
WA8536039Medicaid
ID808281600Medicaid
WAG8882910Medicare PIN
ID11960481Medicare PIN
ID11960483Medicare PIN
WA8536039Medicaid