Provider Demographics
NPI:1275639502
Name:WU, BENJAMIN
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
Last Name:WU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 60TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-4220
Mailing Address - Country:US
Mailing Address - Phone:718-484-3225
Mailing Address - Fax:
Practice Address - Street 1:730 60TH ST FL 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-4220
Practice Address - Country:US
Practice Address - Phone:718-484-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217687174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02136607Medicaid
NYH25418Medicare UPIN
NY0D3562Medicare ID - Type Unspecified