Provider Demographics
NPI:1154495083
Name:BENARD, JAY KENNETH (DPM)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:KENNETH
Last Name:BENARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 VALENCIA ST
Mailing Address - Street 2:SUITE #804
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4412
Mailing Address - Country:US
Mailing Address - Phone:415-392-5626
Mailing Address - Fax:415-392-5632
Practice Address - Street 1:1580 VALENCIA ST
Practice Address - Street 2:SUITE #804
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4412
Practice Address - Country:US
Practice Address - Phone:415-392-5626
Practice Address - Fax:415-392-5632
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2434213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE000320Medicaid
CAT11323Medicare UPIN
CA000E24340Medicare PIN
4689020001Medicare NSC