Provider Demographics
NPI:1710950589
Name:BENSCH, GREGORY WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WILLIAM
Last Name:BENSCH
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 1:4628 GEORGETOWN PL
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6204
Mailing Address - Country:US
Mailing Address - Phone:209-478-6177
Mailing Address - Fax:209-478-6219
Practice Address - Street 1:4628 GEORGETOWN PL
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6204
Practice Address - Country:US
Practice Address - Phone:209-478-6177
Practice Address - Fax:209-478-6219
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61795174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A617950Medicaid
CAZZZ75721ZOtherMEDI-CAL GROUP ID NUMBER
CAA61795Medicare ID - Type Unspecified
CA00A617950Medicaid