Provider Demographics
NPI:1265584924
Name:BENTON, CALVIN BOYD (MD)
Entity type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:BOYD
Last Name:BENTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3669
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95402-3669
Mailing Address - Country:US
Mailing Address - Phone:707-535-4330
Mailing Address - Fax:707-535-4311
Practice Address - Street 1:3031 TELEGRAPH AVE
Practice Address - Street 2:SUITE 217
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2053
Practice Address - Country:US
Practice Address - Phone:510-981-8222
Practice Address - Fax:510-568-8848
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC34382208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C343820Medicaid
CAA35602Medicare UPIN
CA00C343820Medicaid