Provider Demographics
NPI:1972245140
Name:CARLOS, BENJAMIN JR (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:CARLOS
Suffix:JR
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13811 W MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-8303
Mailing Address - Country:US
Mailing Address - Phone:602-515-2270
Mailing Address - Fax:
Practice Address - Street 1:7810 N US HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-6255
Practice Address - Country:US
Practice Address - Phone:928-522-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-32270208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation