Provider Demographics
NPI:1033142526
Name:BENCH, TRAVIS JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:JAMES
Last Name:BENCH
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:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:631-638-4170
Practice Address - Street 1:HSC T16 080
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8167
Practice Address - Country:US
Practice Address - Phone:631-444-1060
Practice Address - Fax:631-444-1054
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00245267207R00000X
NY245267207R00000X, 207RC0000X, 390200000X
NY006594363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03424935Medicaid
NY245267OtherNYS LICENSE
NYA400061964Medicare PIN
NYFB2128901OtherDEA