Provider Demographics
NPI:1386755809
Name:BENNETT, JASON A (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 N MEDICAL DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-1100
Mailing Address - Country:US
Mailing Address - Phone:801-581-2121
Mailing Address - Fax:
Practice Address - Street 1:15 N MEDICAL DR STE 1100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-1100
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429260207ZP0102X
LAMD.205664207ZP0102X
WV21356207ZP0102X
FLME154997207ZP0102X
UT13423479-1205207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017445660001Medicaid
PA156840OtherGATEWAY
MS03223248Medicaid
FL114105000Medicaid
7905789OtherCIGNA
LA2304313Medicaid
000000493642OtherANTHEM
PA1904630OtherHIGHMARK
1393196OtherAETNA HMOS
OH2698906Medicaid
77644605OtherAETNA PPOS
000000493642OtherANTHEM
P00355423Medicare ID - Type UnspecifiedRAILROAD
LA2304313Medicaid