Provider Demographics
NPI:1417901067
Name:LISH, BENJAMIN TETSU (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:TETSU
Last Name:LISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 OLIVAS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7672
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-667-2865
Practice Address - Street 1:120 N ASHWOOD AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1810
Practice Address - Country:US
Practice Address - Phone:805-658-5800
Practice Address - Fax:805-639-0786
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08609FMedicaid
CAZZT40394FMedicaid
CARHM08608FMedicaid
CARHM18553HMedicaid
CA050394OtherBLUE CROSS
CA95-1683892OtherOTHER INSURANCE
CAWA67012AMedicare ID - Type UnspecifiedPPIN
CA058609Medicare ID - Type UnspecifiedRH MEDICARE
CAA67012Medicare ID - Type UnspecifiedPPIN
CARHM08609FMedicaid
CARHM08608FMedicaid
CA058553Medicare ID - Type UnspecifiedRH MEDICARE
CAZZT40394FMedicaid