Provider Demographics
NPI:1396731469
Name:BENNION, JEFFREY GREEN (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GREEN
Last Name:BENNION
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2245 N 400 E
Mailing Address - Street 2:STE 301
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1892
Mailing Address - Country:US
Mailing Address - Phone:435-753-7880
Mailing Address - Fax:435-753-5845
Practice Address - Street 1:2245 N 400 E
Practice Address - Street 2:STE 301
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1892
Practice Address - Country:US
Practice Address - Phone:435-753-7880
Practice Address - Fax:435-753-5845
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT274201-1205207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID7054OtherIDAHO BOARD OF PHARMACY
UT274201-9915OtherUTAH CONTROLLED SUBSTANCE
IDM-6924OtherIDAHO STATE LICENSE
IDM-6924OtherIDAHO STATE LICENSE
ID7054OtherIDAHO BOARD OF PHARMACY