Provider Demographics
NPI:1659957819
Name:HIGGINBOTHAM, BENJAMIN M
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:M
Last Name:HIGGINBOTHAM
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:PO BOX 640256
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94164-0256
Mailing Address - Country:US
Mailing Address - Phone:712-355-2501
Mailing Address - Fax:
Practice Address - Street 1:1445 BUSH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5520
Practice Address - Country:US
Practice Address - Phone:415-972-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker