Provider Demographics
NPI:1295176626
Name:STORK, BENJAMIN FAIR (DO, MPH)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:FAIR
Last Name:STORK
Suffix:
Gender:M
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 WINROW RD
Mailing Address - Street 2:
Mailing Address - City:FORT HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613-5080
Mailing Address - Country:US
Mailing Address - Phone:520-533-5574
Mailing Address - Fax:
Practice Address - Street 1:2240 WINROW RD
Practice Address - Street 2:
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613-5080
Practice Address - Country:US
Practice Address - Phone:520-533-5574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004570A2083X0100X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02004570AOtherMEDICAL LICENSE