Provider Demographics
NPI:1659912863
Name:FALFAS, BENJAMIN ANDREW
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ANDREW
Last Name:FALFAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-9363
Mailing Address - Country:US
Mailing Address - Phone:330-424-1468
Mailing Address - Fax:
Practice Address - Street 1:966 N MARKET ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-9363
Practice Address - Country:US
Practice Address - Phone:330-424-1468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171633171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH171633Medicaid