Provider Demographics
NPI:1255369104
Name:MUSCHA, BENNIE WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:BENNIE
Middle Name:WILLIAM
Last Name:MUSCHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:W
Other - Last Name:MUSCHA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1917 SOUTH CRISMON ROAD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:480-610-7100
Mailing Address - Fax:480-610-7115
Practice Address - Street 1:1917 SOUTH CRISMON ROAD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-610-7100
Practice Address - Fax:480-610-7115
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6633207Q00000X
AZ42575207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11681OtherBCBS
ND17619Medicaid
ND11681OtherBCBS
F58903Medicare UPIN