Provider Demographics
NPI:1215426812
Name:TACK, BENJAMIN (DO)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:TACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-1347
Mailing Address - Country:US
Mailing Address - Phone:845-853-5739
Mailing Address - Fax:
Practice Address - Street 1:189 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:ROSELAND
Practice Address - State:NJ
Practice Address - Zip Code:07068-1347
Practice Address - Country:US
Practice Address - Phone:845-853-5739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB11904700207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease