Provider Demographics
NPI:1417167057
Name:BENJAMIN, LATANYA TAMARA (MD)
Entity Type:Individual
Prefix:DR
First Name:LATANYA
Middle Name:TAMARA
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11076 MERIDIAN DR N
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33076-4592
Mailing Address - Country:US
Mailing Address - Phone:954-821-1331
Mailing Address - Fax:
Practice Address - Street 1:5200 S UNIVERSITY DR STE 102
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5316
Practice Address - Country:US
Practice Address - Phone:954-242-4275
Practice Address - Fax:954-530-5562
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110104207N00000X
FLME88650207N00000X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014388600Medicaid
FLIE083ZMedicare PIN