Provider Demographics
NPI:1457364333
Name:TEITELBAUM, BENJAMIN J (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:TEITELBAUM
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 1:1351 E SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3342
Mailing Address - Country:US
Mailing Address - Phone:559-432-3303
Mailing Address - Fax:559-432-1468
Practice Address - Street 1:1351 E SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-432-3303
Practice Address - Fax:559-432-3303
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG88530207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32007300Medicaid
WI32007300Medicaid
P00303197Medicare PIN