Provider Demographics
NPI:1568561579
Name:ISIP, BENJAMIN C (RPT/L)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:C
Last Name:ISIP
Suffix:
Gender:M
Credentials:RPT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12832 GARDEN GROVE BLVD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-2002
Mailing Address - Country:US
Mailing Address - Phone:714-534-1100
Mailing Address - Fax:714-534-1140
Practice Address - Street 1:12832 GARDEN GROVE BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-2002
Practice Address - Country:US
Practice Address - Phone:714-534-1100
Practice Address - Fax:714-534-1140
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT16394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT16394CMedicare PIN