Provider Demographics
NPI:1962898080
Name:HEAD, BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:HEAD
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 1:705 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:AK
Mailing Address - Zip Code:99574-2290
Mailing Address - Country:US
Mailing Address - Phone:907-424-3622
Mailing Address - Fax:907-424-3275
Practice Address - Street 1:705 2ND STREET
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:AK
Practice Address - Zip Code:99574-2290
Practice Address - Country:US
Practice Address - Phone:907-424-3622
Practice Address - Fax:907-424-3275
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK139968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program