Provider Demographics
NPI:1164738159
Name:DEVRIES, BENJAMIN (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:DEVRIES
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 1:1573 S FORT HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-2004
Mailing Address - Country:US
Mailing Address - Phone:727-584-8777
Mailing Address - Fax:727-584-8772
Practice Address - Street 1:1573 S FORT HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756
Practice Address - Country:US
Practice Address - Phone:727-584-8777
Practice Address - Fax:727-584-8772
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO2557207Q00000X
FLOS11511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103871800Medicaid