Provider Demographics
NPI:1619975232
Name:MARTIN, BENNY JOE (DO)
Entity Type:Individual
Prefix:DR
First Name:BENNY
Middle Name:JOE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:BEN
Other - Middle Name:J
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:400 CRAVEN RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4201
Mailing Address - Country:US
Mailing Address - Phone:800-290-5000
Mailing Address - Fax:
Practice Address - Street 1:400 CRAVEN RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4201
Practice Address - Country:US
Practice Address - Phone:800-290-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114292Medicaid
OK100256740DMedicaid
IL06032182OtherBLUE CROSS BLUE SHIELD
IL06032182OtherBLUE CROSS BLUE SHIELD
OK100256740DMedicaid
ILK29947Medicare PIN