MEDICARE: BENJAMIN B ROA PHD

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
1	207SG0203X	Clinical Molecular Genetics Physician	ROAXB1	NY

General Provider Information

NPI Number	:	1679145528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN B ROA PHD

Provider Business Mailing Address
First Line	:	322 N 2200 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-2922
Country	:	US
Telephone Number	:	801-584-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	322 N 2200 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-2922
Country	:	US
Telephone Number	:	801-584-3600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2021
Last Update Date	:	08/19/2025

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