Provider Demographics
NPI:1497827133
Name:BENJAMIN, ZAN (MD)
Entity type:Individual
Prefix:
First Name:ZAN
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 W 6TH ST
Mailing Address - Street 2:SUITE #113
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3294
Mailing Address - Country:US
Mailing Address - Phone:951-278-8910
Mailing Address - Fax:951-278-9895
Practice Address - Street 1:1307 W 6TH ST
Practice Address - Street 2:SUITE #113
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3294
Practice Address - Country:US
Practice Address - Phone:951-278-8910
Practice Address - Fax:951-278-9895
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54540305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABB4667537OtherDEA LIC#