Healthcare Provider Details

I. General information

NPI: 1083155337
Provider Name (Legal Business Name): ERIC BENNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2017
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 CHANNING WAY
IDAHO FALLS ID
83404-7510
US

IV. Provider business mailing address

2775 CHANNING WAY
IDAHO FALLS ID
83404-7510
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-0133
  • Fax:
Mailing address:
  • Phone: 208-529-9060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10939737-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-14988
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: