Provider Demographics
NPI:1720209018
Name:HOM, BENJAMIN KARL (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KARL
Last Name:HOM
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:PO BOX 9649
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-4649
Mailing Address - Country:US
Mailing Address - Phone:208-472-8100
Mailing Address - Fax:208-472-8172
Practice Address - Street 1:1055 N CURTIS ROAD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1309
Practice Address - Country:US
Practice Address - Phone:208-367-2161
Practice Address - Fax:208-367-2989
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-112842085R0202X
ORMD1536382085R0202X
390200000X
VA01012407752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1197566Medicare PIN
ORR159804Medicare PIN