Provider Demographics
NPI:1023350113
Name:FAN, BENSEN BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:BENSEN
Middle Name:BENJAMIN
Last Name:FAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1222 S ORANGE AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:321-841-3040
Practice Address - Street 1:1222 S ORANGE AVE FL 5
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:844-362-1735
Practice Address - Fax:321-841-3040
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME152894207X00000X, 207XP3100X
CAA154107207X00000X
NJ25MA10638900207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112713000Medicaid