Provider Demographics
NPI:1891786455
Name:BLANK, BENJAMIN IRA (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:IRA
Last Name:BLANK
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 1:402 LIPPINCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4112
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:
Practice Address - Street 1:1300 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:NJ
Practice Address - Zip Code:08029-1308
Practice Address - Country:US
Practice Address - Phone:856-939-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06092600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7016905Medicaid
NJG28258Medicare UPIN
NJ7016905Medicaid