Provider Demographics
NPI:1205943263
Name:BENJAMIN, JENSE (MD, MS, FRCS)
Entity type:Individual
Prefix:
First Name:JENSE
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:MD, MS, FRCS
Other - Prefix:
Other - First Name:JENSE
Other - Middle Name:
Other - Last Name:BENJAMIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:125 E GRUBB DR STE 109
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3402
Mailing Address - Country:US
Mailing Address - Phone:972-285-6349
Mailing Address - Fax:972-289-6717
Practice Address - Street 1:125 E GRUBB DR STE 109
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3402
Practice Address - Country:US
Practice Address - Phone:972-285-6349
Practice Address - Fax:972-289-6717
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2800208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148370310Medicaid
TX8D1869Medicare PIN
TX8B8007Medicare PIN
TXG66616Medicare UPIN