Provider Demographics
NPI:1205844677
Name:BENBRAHIM, AZIZ (MD)
Entity Type:Individual
Prefix:
First Name:AZIZ
Middle Name:
Last Name:BENBRAHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1065
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1065
Mailing Address - Country:US
Mailing Address - Phone:508-595-0531
Mailing Address - Fax:508-829-5367
Practice Address - Street 1:455 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2121
Practice Address - Country:US
Practice Address - Phone:203-238-2691
Practice Address - Fax:203-235-3128
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038487208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001374875Medicaid
CT020001527Medicare ID - Type Unspecified
CT001374875Medicaid
H13070Medicare UPIN