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General NPI Number Information
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NPI Number | 1083155337
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Entity Type | Individual
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Provider Name | ERIC BENNETT M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/19/2017
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Last Update Date | 12/02/2020
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Provider Practice Location Address
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Address Line | 2775 CHANNING WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7510
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Country | US
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Telephone | 208-524-0133
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Fax |
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Provider Business Mailing Address
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Address Line | 2775 CHANNING WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7510
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Country | US
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Telephone | 208-529-9060
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 10939737-1205
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M-14988
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License Number State | ID
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