Provider Demographics
NPI:1811239247
Name:WHITE, BENJAMIN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:WHITE
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 1:8407 S DYNASTY WAY
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6046
Mailing Address - Country:US
Mailing Address - Phone:269-240-0564
Mailing Address - Fax:
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-2360
Practice Address - Country:US
Practice Address - Phone:269-240-0564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-24
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9158424-1205208000000X
PAMD4708642080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics