Provider Demographics
NPI:1528695194
Name:AMENDOLARA, BENJAMIN I (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:I
Last Name:AMENDOLARA
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 1:1203 S RIMPAU BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3020
Mailing Address - Country:US
Mailing Address - Phone:551-804-1673
Mailing Address - Fax:
Practice Address - Street 1:627 SAN JULIAN ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014-2411
Practice Address - Country:US
Practice Address - Phone:213-719-1737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1939672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty