Provider Demographics
NPI:1558332072
Name:BENJAMIN, JONATHAN WAYNE (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WAYNE
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 1:2185 WANTAGH AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3917
Mailing Address - Country:US
Mailing Address - Phone:516-785-3900
Mailing Address - Fax:516-783-0033
Practice Address - Street 1:2185 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3917
Practice Address - Country:US
Practice Address - Phone:516-785-3900
Practice Address - Fax:516-783-0033
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144781207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC06714Medicare UPIN
NY20D8334001Medicare PIN
NY20D831Medicare ID - Type Unspecified