Provider Demographics
NPI:1124297148
Name:SELJESTAD, BENJAMIN CLARK (OD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:CLARK
Last Name:SELJESTAD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 OLD CLEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89705-6853
Mailing Address - Country:US
Mailing Address - Phone:775-884-2020
Mailing Address - Fax:
Practice Address - Street 1:700 OLD CLEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89705-6853
Practice Address - Country:US
Practice Address - Phone:775-884-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-23
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVU93407Medicare UPIN
NVV39992Medicare PIN