Provider Demographics
NPI:1366433138
Name:BENJAMIN, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:BENJAMIN
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 1:5201 WILLOW SPRINGS RD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6537
Mailing Address - Country:US
Mailing Address - Phone:708-354-2008
Mailing Address - Fax:708-354-2092
Practice Address - Street 1:5201 WILLOW SPRINGS RD
Practice Address - Street 2:SUITE 450
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6537
Practice Address - Country:US
Practice Address - Phone:708-354-2008
Practice Address - Fax:708-354-2092
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095352207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1532015OtherBLUE CROSS BLUE SHIELD
ILG55747Medicare UPIN
IL1272400001Medicare NSC
IL211282Medicare PIN