Provider Demographics
NPI:1124000872
Name:SHILLER, BENNETT J (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:J
Last Name:SHILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6386 ALVARADO CT
Mailing Address - Street 2:#310
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4905
Mailing Address - Country:US
Mailing Address - Phone:619-229-5050
Mailing Address - Fax:619-287-0833
Practice Address - Street 1:6386 ALVARADO CT
Practice Address - Street 2:#310
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4905
Practice Address - Country:US
Practice Address - Phone:619-229-5050
Practice Address - Fax:619-287-0833
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2008-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G711200Medicaid
CAE92528Medicare UPIN
CAWG71120JMedicare ID - Type Unspecified