Provider Demographics
NPI:1316900673
Name:BENNER, ROBERT B (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:BENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 EL CAMINO REAL
Mailing Address - Street 2:SUITE 155
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010
Mailing Address - Country:US
Mailing Address - Phone:650-692-4415
Mailing Address - Fax:650-259-1030
Practice Address - Street 1:1720 EL CAMINO REAL
Practice Address - Street 2:SUITE 155
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010
Practice Address - Country:US
Practice Address - Phone:650-692-4415
Practice Address - Fax:650-259-1030
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG034384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A45907Medicare UPIN
00G343840Medicare ID - Type Unspecified