Provider Demographics
NPI:1902896780
Name:BENJAMIN, MARK D (M D)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917368
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7368
Mailing Address - Country:US
Mailing Address - Phone:727-793-9300
Mailing Address - Fax:727-793-0052
Practice Address - Street 1:1106 DRUID RD S
Practice Address - Street 2:SUITE 302
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3846
Practice Address - Country:US
Practice Address - Phone:727-441-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME468432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048344300Medicaid
FL300013292OtherRR MEDICARE
FL07281OtherBCBS
FL07281OtherBCBS
FLD51892Medicare UPIN
FL07281ZMedicare PIN