Provider Demographics
NPI:1083749212
Name:BENOWITZ, IRVIN S (DO)
Entity Type:Individual
Prefix:
First Name:IRVIN
Middle Name:S
Last Name:BENOWITZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 FLOWER ST STE A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3000
Mailing Address - Country:US
Mailing Address - Phone:818-637-2000
Mailing Address - Fax:818-242-8761
Practice Address - Street 1:191 S BUENA VISTA ST
Practice Address - Street 2:STE. 420
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4554
Practice Address - Country:US
Practice Address - Phone:818-557-7399
Practice Address - Fax:818-848-1543
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4228207Q00000X, 207QG0300X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX42280Medicaid
CA00AX42280Medicaid
CAW20A4228AMedicare PIN