BENJAMIN, GARY GORDON (MD)

Provider Demographics

• NPI: 1164595286
• Name: BENJAMIN, GARY GORDON (MD)
• Entity Type: Individual
• Prefix: DR
• First Name: GARY
• Middle Name: GORDON
• Last Name: BENJAMIN
• Gender: M
• Credentials: MD
• Other - First Name: GORDON
• Other - Last Name: BENJAMIN
• Other - Last Name Type: Professional Name
• Other - Credentials: MD
• Mailing Address - Street 1: PO BOX 1535
• Mailing Address - City: TACOMA
• Mailing Address - State: WA
• Mailing Address - Zip Code: 98401-1535
• Mailing Address - Country: US
• Mailing Address - Phone: 253-761-4200
• Mailing Address - Fax: 253-383-3553
• Practice Address - Street 1: 1304 FAWCETT AVE STE 100
• Practice Address - City: TACOMA
• Practice Address - State: WA
• Practice Address - Zip Code: 98402-1900
• Practice Address - Country: US
• Practice Address - Phone: 253-761-4200
• Practice Address - Fax: 253-761-4201
• Is Sole Proprietor?: No
• Enumeration Date: 2006-11-16
• Last Update Date: 2019-05-13

Provider Licenses

State	License ID	Taxonomies
WA	MD00034148	2085R0202X, 2085R0204X
OR	MD21111	2085R0202X, 2085R0204X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	2085R0204X	Allopathic & Osteopathic Physicians	Radiology	Vascular & Interventional Radiology
No	2085R0202X	Allopathic & Osteopathic Physicians	Radiology	Diagnostic Radiology

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WA	0372658	Other	L&I-DIAGNOSTIC IMAGING NW
WA	0127162	Other	L&I-TRA KING COUNTY
OR	500670859	Medicaid
WA	1031136	Medicaid
WA	0186167	Other	L&I-UNION AVE OPEN MRI
WA	0335999	Other	L&I-TRA REST OF WA
WA	BE0875	Other	REGENCE BLUE SHIELD
WA	8238883	Medicaid
WA	7252BE	Other	REGENCE BLUE SHIELD UNION AVE OPEN MRI
WA	G74025	Medicare UPIN
WA	7087158	Medicare PIN
WA	255941	Medicare PIN
WA	1326373713	Medicare PIN
WA	0249577	Other	LABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST
WA	BE0875	Other	REGENCE BLUE SHIELD
WA	127162	Other	LABOR AND INDUSTRIES/WORK COMP
WA	8238883	Medicaid
WA	P07252	Medicare PIN
WA	AB35572	Medicare PIN
WA	7820707	Medicare PIN
WA	186167	Other	LABOR AND INDUSTRIES/WORK COMP UNION AVE OPEN MRI
WA	G8851512	Medicare PIN
WA	249518	Medicare PIN