Provider Demographics
NPI:1760412977
Name:JOHNNY C. BENJAMIN JR. M.D., PA
Entity Type:Organization
Organization Name:JOHNNY C. BENJAMIN JR. M.D., PA
Other - Org Name:PRO SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN ASSIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:P
Authorized Official - Last Name:MULLIKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-978-7808
Mailing Address - Street 1:1355 37TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7320
Mailing Address - Country:US
Mailing Address - Phone:772-978-7808
Mailing Address - Fax:772-978-9320
Practice Address - Street 1:1355 37TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7320
Practice Address - Country:US
Practice Address - Phone:772-978-7808
Practice Address - Fax:772-978-9320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45410OtherBLUE CROSS BLUE SHIELD FL
FL4295190001Medicare NSC
FLK1518Medicare PIN