Provider Demographics
NPI:1972512655
Name:BENSON, JACK NILS (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:NILS
Last Name:BENSON
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 1:19841 N 27TH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4005
Mailing Address - Country:US
Mailing Address - Phone:623-582-6420
Mailing Address - Fax:623-582-6720
Practice Address - Street 1:19841 N 27TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4005
Practice Address - Country:US
Practice Address - Phone:623-582-6420
Practice Address - Fax:623-582-6720
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1521208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0066690OtherBLUECROSSBLUESHIELDAZ
AZ1Z0539OtherHEALTHNET
AZ4316747OtherAETNA
AZ246729Medicaid
AZ1Z0539OtherHEALTHNET
AZAZ0066690OtherBLUECROSSBLUESHIELDAZ