Provider Demographics
NPI:1073833497
Name:SERVICE, BENJAMIN C (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:C
Last Name:SERVICE
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 1:7243 DELLA DR
Mailing Address - Street 2:STE B
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5106
Mailing Address - Country:US
Mailing Address - Phone:321-842-0060
Mailing Address - Fax:321-842-0084
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:407-423-7777
Practice Address - Fax:407-423-1380
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60545556207X00000X
FLME 124973207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1073833497Medicaid
FLME124973OtherMEDICAL LICENSE
FL017843500Medicaid
FLME124973OtherMEDICAL LICENSE
WA8940382Medicare PIN