Provider Demographics
NPI:1508885278
Name:BENSON, STEPHEN ANDREW (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANDREW
Last Name:BENSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MARIN ST
Mailing Address - Street 2:SUITE 290
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4236
Mailing Address - Country:US
Mailing Address - Phone:805-497-6979
Mailing Address - Fax:805-777-7028
Practice Address - Street 1:555 MARIN ST
Practice Address - Street 2:SUITE 290
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4236
Practice Address - Country:US
Practice Address - Phone:805-497-6979
Practice Address - Fax:805-777-7028
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4426213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW22604AOtherGROUP MEDICARE PIN
CAW22604OtherGROUP MEDICARE PIN
CA000E44260Medicaid
CAW22604OtherGROUP MEDICARE PIN
CAW22604AOtherGROUP MEDICARE PIN
CAAU306ZMedicare PIN