Provider Demographics
NPI:1457441214
Name:LOOS, BENJAMIN M (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:M
Last Name:LOOS
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 1:2700 GRANT ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520
Mailing Address - Country:US
Mailing Address - Phone:925-685-7400
Mailing Address - Fax:925-685-0917
Practice Address - Street 1:2700 GRANT ST
Practice Address - Street 2:SUITE 104
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520
Practice Address - Country:US
Practice Address - Phone:925-685-7400
Practice Address - Fax:925-685-0917
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71850207Y00000X, 207YS0123X, 207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ21406ZOtherMEDICARE GR
CAA781550OtherLICENSE
CAA781550OtherLICENSE
H86476Medicare UPIN