Provider Demographics
NPI:1295180982
Name:FORD BENCH, KELSEY L (MD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:L
Last Name:FORD BENCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:L
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1200 N STATE ST
Mailing Address - Street 2:CLINIC TOWER, SUITE A7D
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:CLINIC TOWER, SUITE A7D
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-409-1945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61021863207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program