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NPI Code Detail

MEDICARE: BENJAMIN G LAROSE D.O.

MEDICARE: BENJAMIN G LAROSE D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician50479251204UT

General Provider Information

NPI Number : 1568690188
Entity Type Code : Individual
Provider Name (Legal Business Name) : BENJAMIN G LAROSE D.O.
Provider Business Mailing Address
First Line : PO BOX 27128
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84127-0128
Country : US
Telephone Number : 801-387-5300
Fax Number :
Provider Business Practice Location Address
First Line : 4403 HARRISON BLVD STE 700A
Second Line :
City : OGDEN
State : UT
Zip : 84403-3295
Country : US
Telephone Number : 801-387-5300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/23/2009
Last Update Date : 02/01/2010

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