Provider Demographics
NPI:1679852420
Name:BOYD, BENJAMIN SAMUEL (PT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:SAMUEL
Last Name:BOYD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:603 LITTLE LN
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2178
Mailing Address - Country:US
Mailing Address - Phone:510-869-6511
Mailing Address - Fax:510-869-6282
Practice Address - Street 1:1900 POWELL ST
Practice Address - Street 2:STE 6079
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1811
Practice Address - Country:US
Practice Address - Phone:510-593-7062
Practice Address - Fax:510-336-2654
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27777225100000X, 2251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFM306ZOtherMEDICARE PTAN