Provider Demographics
NPI:1083702997
Name:TRIPP, BENJAMIN M (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:TRIPP
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:5130 LINTON BLVD
Practice Address - Street 2:SUITE C-1
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6596
Practice Address - Country:US
Practice Address - Phone:561-499-8048
Practice Address - Fax:561-499-8762
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 73510208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374221OtherAVMED
FLQMP000003834662OtherMOLINA
FLP01591878OtherRR MEDICARE
FL1959057OtherCIGNA
FL41440OtherBCBS
FLP971112OtherOPTIMUM
FL8100OtherDIMENSION HEALTH
FL5866760OtherAETNA
FL1178610OtherWELLCARE
FLP1035318OtherFREEDOM
FL374221OtherAVMED
FLG59253Medicare UPIN
FL5866760OtherAETNA
FL41440AMedicare PIN