Provider Demographics
NPI:1790279966
Name:FAY, BENJAMIN JUSTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JUSTIN
Last Name:FAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5045
Mailing Address - Country:US
Mailing Address - Phone:718-670-2000
Mailing Address - Fax:
Practice Address - Street 1:5645 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:718-670-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315946207PH0002X, 207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative MedicineGroup - Single Specialty