Provider Demographics
NPI:1104247444
Name:GROUNDS, BENJAMIN ERIC
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ERIC
Last Name:GROUNDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 STURGIS ROAD
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278
Mailing Address - Country:US
Mailing Address - Phone:760-830-2117
Mailing Address - Fax:
Practice Address - Street 1:1145 STURGIS ROAD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278-8275
Practice Address - Country:US
Practice Address - Phone:760-830-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101259691207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program