Provider Demographics
NPI:1225007974
Name:BENCH, GARY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROBERT
Last Name:BENCH
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 1:7930 FROST ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2737
Mailing Address - Country:US
Mailing Address - Phone:858-565-0104
Mailing Address - Fax:858-565-0194
Practice Address - Street 1:7930 FROST ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2737
Practice Address - Country:US
Practice Address - Phone:858-565-0104
Practice Address - Fax:858-565-0194
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA035873208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A358730Medicaid
CAA27928Medicare UPIN
CAWA35873CMedicare ID - Type Unspecified