Provider Demographics
NPI:1821057779
Name:BENJAMIN, JEFF A (DO)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:A
Last Name:BENJAMIN
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 1:8170 ROURK STREET
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4127
Mailing Address - Country:US
Mailing Address - Phone:843-449-2336
Mailing Address - Fax:843-479-2505
Practice Address - Street 1:8170 ROURK ST
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4127
Practice Address - Country:US
Practice Address - Phone:843-449-2336
Practice Address - Fax:843-497-2505
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC05012084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2023740OtherEVOLUTIONS
PA01838875Medicaid
WV1061000OtherWORK COMP
SC3099820OtherGHI
SC434035OtherONE HEALTH PLAN
NC6906038Medicaid
NCA156OtherNC UHC
SC1189849OtherFIRST HEALTH
SC7251177OtherAETNA
SC82645OtherMEDCOST
SC005014Medicaid
SC0504464OtherPHP
SC521523OtherFOCUS HEALTHCARE
SCG70940Medicare UPIN
SC005014Medicaid