Provider Demographics
NPI:1053309005
Name:LLANES, BENJAMIN P (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:P
Last Name:LLANES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9580 BLACK MOUNTAIN RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4522
Mailing Address - Country:US
Mailing Address - Phone:858-536-8952
Mailing Address - Fax:858-536-8951
Practice Address - Street 1:9580 BLACK MOUNTAIN RD
Practice Address - Street 2:SUITE J
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4522
Practice Address - Country:US
Practice Address - Phone:858-536-8952
Practice Address - Fax:858-536-8951
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8782T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0087820Medicaid
CAU34697Medicare UPIN
CAOP8782Medicare ID - Type Unspecified