Provider Demographics
NPI:1437902889
Name:PHELPS, BENJAMIN MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MATTHEW
Last Name:PHELPS
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 1:2863 GOLDEN POND BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-7665
Mailing Address - Country:US
Mailing Address - Phone:571-577-7924
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST DEPT 5000
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5000
Practice Address - Country:US
Practice Address - Phone:571-577-7924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program