Provider Demographics
NPI:1518427343
Name:GIFFORD, BENJAMIN GRANT (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:GRANT
Last Name:GIFFORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2254 E NORA ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-1562
Mailing Address - Country:US
Mailing Address - Phone:480-216-0358
Mailing Address - Fax:
Practice Address - Street 1:10230 W HAPPY VALLEY PKWY STE 100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-4692
Practice Address - Country:US
Practice Address - Phone:623-561-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
AZ008903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program