Provider Demographics
NPI:1932104007
Name:BENJAMIN, KENNETH JAMES (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 THOMAS JOHNSON DR
Mailing Address - Street 2:STE 4
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4398
Mailing Address - Country:US
Mailing Address - Phone:301-695-9669
Mailing Address - Fax:301-695-0346
Practice Address - Street 1:198 THOMAS JOHNSON DR
Practice Address - Street 2:STE 4
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4398
Practice Address - Country:US
Practice Address - Phone:301-695-9669
Practice Address - Fax:301-695-0346
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
MD00592213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD998448OtherAETNA HEALTHCARE
MDK374OtherBLUE CROSS BLUE SHIELD
MD4081479OtherAETNA HEALTHCARE
DC9502OtherBLUE CROSS BLUE CHOICE
MD385141OtherUNITED HEALTHCARE
MDT30909Medicare UPIN
MDK374Medicare ID - Type Unspecified
DC9502OtherBLUE CROSS BLUE CHOICE
MD192765Medicare ID - Type Unspecified