Provider Demographics
NPI:1811171366
Name:PLATA, BENJAMIN NATO (PASTOR)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:NATO
Last Name:PLATA
Suffix:
Gender:M
Credentials:PASTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-2439
Mailing Address - Country:US
Mailing Address - Phone:619-434-6632
Mailing Address - Fax:619-434-4919
Practice Address - Street 1:616 E 8TH ST
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2439
Practice Address - Country:US
Practice Address - Phone:619-434-6632
Practice Address - Fax:619-434-4919
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABL3225-07171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD08608787OtherEDI SUBMITTER ID
CA5680520001Medicare NSC