Provider Demographics
NPI:1770516882
Name:ANSELL, BENJAMIN JESSE (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JESSE
Last Name:ANSELL
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 UCLA MEDICAL PLAZA SUITE 525
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-794-4881
Practice Address - Fax:310-825-4704
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77397207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO00G773970Medicaid
CAWG77397AMedicare PIN
CO00G773970Medicaid