Provider Demographics
NPI:1235516675
Name:HEGENBARTH, BENJAMIN J (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:J
Last Name:HEGENBARTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 N HALF HITCH RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1462
Mailing Address - Country:US
Mailing Address - Phone:602-418-0121
Mailing Address - Fax:
Practice Address - Street 1:14981 NTH 174 DR.
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388
Practice Address - Country:US
Practice Address - Phone:602-418-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ007738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ007738OtherMEDICAL LICENSE
FH5441023OtherDEA