Provider Demographics
NPI:1720016637
Name:BENSON, T LEROY (MD)
Entity Type:Individual
Prefix:
First Name:T
Middle Name:LEROY
Last Name:BENSON
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 1:250 BON AIR RD
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1702
Mailing Address - Country:US
Mailing Address - Phone:415-454-2218
Mailing Address - Fax:415-485-6862
Practice Address - Street 1:250 BON AIR RD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-454-2218
Practice Address - Fax:415-485-6862
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC28884207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C288840Medicaid
CA00C288840Medicaid
CA00C288840Medicare PIN