Provider Demographics
NPI:1235463944
Name:PALMER, BEN C (OD)
Entity Type:Individual
Prefix:DR
First Name:BEN
Middle Name:C
Last Name:PALMER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-8979
Mailing Address - Country:US
Mailing Address - Phone:805-929-1982
Mailing Address - Fax:805-929-5052
Practice Address - Street 1:125 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-8979
Practice Address - Country:US
Practice Address - Phone:805-929-1982
Practice Address - Fax:805-929-5052
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13794152W00000X
ID100188152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1235463944OtherTYPE I (INDIVIDUAL) NPI
CA1235463944Medicaid
CA1346539095OtherTYPE II (GROUP) NPI
CAFI860AOtherGROUP MEDICARE PTAN
CA1235463944Medicaid