Provider Demographics
NPI:1194027037
Name:JAQUISH, BENJAMIN PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:PAUL
Last Name:JAQUISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:75 PRINGLE WAY
Mailing Address - Street 2:STE 1002
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1475
Mailing Address - Country:US
Mailing Address - Phone:775-323-7500
Mailing Address - Fax:775-789-9208
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:MS-01-390F
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:775-750-6083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-29
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301094774208600000X
TXP92062086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery