Provider Demographics
NPI:1275936270
Name:JIMI O. BENSON MD., INC
Entity Type:Organization
Organization Name:JIMI O. BENSON MD., INC
Other - Org Name:BROADWAY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMI
Authorized Official - Middle Name:OLA
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-466-1078
Mailing Address - Street 1:1351 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5811
Mailing Address - Country:US
Mailing Address - Phone:619-383-6703
Mailing Address - Fax:866-473-3324
Practice Address - Street 1:1351 BROADWAY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5811
Practice Address - Country:US
Practice Address - Phone:619-383-6703
Practice Address - Fax:866-473-3324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116611207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1477751667Medicaid
CA1275936270Medicaid