Provider Demographics
NPI:1336112127
Name:BENSON, BEVERLY J (MD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:J
Last Name:BENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BEVERLY
Other - Middle Name:JEAN
Other - Last Name:KONKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1312 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CALISTOGA
Mailing Address - State:CA
Mailing Address - Zip Code:94515-1442
Mailing Address - Country:US
Mailing Address - Phone:707-942-1113
Mailing Address - Fax:707-942-1463
Practice Address - Street 1:1312 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1442
Practice Address - Country:US
Practice Address - Phone:707-942-1113
Practice Address - Fax:707-942-1463
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG080070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G80070Medicare ID - Type Unspecified
G23076Medicare UPIN
CA00G800700Medicare PIN