Provider Demographics
NPI:1891130258
Name:THAYIL, BENJAMIN (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:THAYIL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW 78TH AVE
Mailing Address - Street 2:APT 422
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3392
Mailing Address - Country:US
Mailing Address - Phone:954-600-5975
Mailing Address - Fax:
Practice Address - Street 1:20354 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-2503
Practice Address - Country:US
Practice Address - Phone:305-652-5277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4836152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision