Provider Demographics
NPI:1932692597
Name:ENCISO, BENJAMIN MANUEL (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MANUEL
Last Name:ENCISO
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:E. 7TH STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:678-925-3893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010032208600000X
NC2023-01649208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery