Healthcare Provider Details

I. General information

NPI: 1659537850
Provider Name (Legal Business Name): BENJAMIN GRANT LAURITZEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 S 1000 E STE 200
PAYSON UT
84651-5592
US

IV. Provider business mailing address

15 S 1000 E STE 200
PAYSON UT
84651-5592
US

V. Phone/Fax

Practice location:
  • Phone: 801-465-2800
  • Fax: 801-465-4770
Mailing address:
  • Phone: 801-465-2800
  • Fax: 801-465-4770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number80037461205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125055456
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier870549057
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: