Provider Demographics
NPI:1922369859
Name:MARSHALL, BENJAMIN GRANT (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:GRANT
Last Name:MARSHALL
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 1:1785 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3221
Mailing Address - Country:US
Mailing Address - Phone:213-269-9612
Mailing Address - Fax:321-268-8433
Practice Address - Street 1:1785 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3221
Practice Address - Country:US
Practice Address - Phone:321-269-9612
Practice Address - Fax:321-269-8433
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD208003207Q00000X
FLTRN 17849207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLS576OtherPTAN
FLME118384OtherMEDICAL LICENSE
MS06552313Medicaid