Provider Demographics
NPI:1710325758
Name:PERRY, BENJAMIN MERRILL (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MERRILL
Last Name:PERRY
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 1:4664 N PENNGROVE WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7442
Mailing Address - Country:US
Mailing Address - Phone:208-898-7467
Mailing Address - Fax:208-398-2120
Practice Address - Street 1:4664 N PENNGROVE WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7442
Practice Address - Country:US
Practice Address - Phone:208-898-7467
Practice Address - Fax:208-398-2120
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO168846207N00000X
IDO1145207ND0101X, 207N00000X
ORPG163364208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice