Provider Demographics
NPI:1164772059
Name:SMITH, BENJAMIN MILLARD (PT, DPT, ATC)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MILLARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16935 W BERNARDO DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1634
Mailing Address - Country:US
Mailing Address - Phone:858-217-5837
Mailing Address - Fax:858-217-5935
Practice Address - Street 1:15725 POMERADO RD
Practice Address - Street 2:SUITE 115
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2068
Practice Address - Country:US
Practice Address - Phone:858-675-7766
Practice Address - Fax:858-675-0043
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA391892251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17215AMedicare PIN
CAW17215Medicare PIN
CACB252983Medicare PIN
CACB252982Medicare PIN