Provider Demographics
NPI:1083603104
Name:BENNOV, BENJAMIN Z (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:Z
Last Name:BENNOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9630 BUSTLETON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3102
Mailing Address - Country:US
Mailing Address - Phone:215-671-1484
Mailing Address - Fax:215-671-1485
Practice Address - Street 1:9630 BUSTLETON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3102
Practice Address - Country:US
Practice Address - Phone:215-671-1484
Practice Address - Fax:215-671-1485
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD037759E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE90142Medicare UPIN