Provider Demographics
NPI:1790216505
Name:CRISP, BENJAMIN GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:GREGORY
Last Name:CRISP
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 1:4207 LAKE BOONE TRL STE 210
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6685
Mailing Address - Country:US
Mailing Address - Phone:919-784-7874
Mailing Address - Fax:919-784-2708
Practice Address - Street 1:4207 LAKE BOONE TRL STE 210
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6685
Practice Address - Country:US
Practice Address - Phone:919-784-7874
Practice Address - Fax:919-784-2708
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA332669208600000X
NC2023-02063208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery