Provider Demographics
NPI:1528189651
Name:BENNINGHOVEN, SCOTT WALD (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:WALD
Last Name:BENNINGHOVEN
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 1:8833 MONTEREY RD STE F
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-7200
Mailing Address - Country:US
Mailing Address - Phone:408-848-3799
Mailing Address - Fax:408-848-5490
Practice Address - Street 1:8833 MONTEREY RD STE F
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-7200
Practice Address - Country:US
Practice Address - Phone:408-848-3799
Practice Address - Fax:408-848-5490
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55118208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G551180Medicaid
CA00G551180Medicaid
CAE38311Medicare UPIN