Provider Demographics
NPI:1952528374
Name:CHAN, BENJAMIN RUSSELL (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:RUSSELL
Last Name:CHAN
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 1:2145 HANNIBAL ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4101
Mailing Address - Country:US
Mailing Address - Phone:801-581-5515
Mailing Address - Fax:
Practice Address - Street 1:650 KOMAS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1215
Practice Address - Country:US
Practice Address - Phone:801-581-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012401102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry