Provider Demographics
NPI:1689604415
Name:BENISCH, DAVID LANCE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LANCE
Last Name:BENISCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 MAIN ST STE 16
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-6922
Mailing Address - Country:US
Mailing Address - Phone:631-423-7000
Mailing Address - Fax:631-423-9276
Practice Address - Street 1:124 MAIN ST STE 16
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-6922
Practice Address - Country:US
Practice Address - Phone:631-423-7000
Practice Address - Fax:631-423-9276
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132568208600000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00425470Medicaid
NY12A811Medicare PIN
NY00425470Medicaid