Provider Demographics
NPI:1841310950
Name:THATCHER, BENJAMIN TODD (DO)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:TODD
Last Name:THATCHER
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 1:1020 S MAIN ST
Mailing Address - Street 2:#300
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-3176
Mailing Address - Country:US
Mailing Address - Phone:801-538-2057
Mailing Address - Fax:801-596-2515
Practice Address - Street 1:1020 S MAIN ST
Practice Address - Street 2:#300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3176
Practice Address - Country:US
Practice Address - Phone:801-538-2057
Practice Address - Fax:801-596-2515
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2012-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT721696512042084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000066966Medicare PIN
UTU000075483Medicare PIN
UTU000076306Medicare PIN