Provider Demographics
NPI:1942508577
Name:TISHMAN, BENJAMIN JACOB (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JACOB
Last Name:TISHMAN
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 1:1730 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3108
Mailing Address - Country:US
Mailing Address - Phone:216-363-2466
Mailing Address - Fax:
Practice Address - Street 1:1730 W 25TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3108
Practice Address - Country:US
Practice Address - Phone:216-363-2466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.010631207P00000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine