Provider Demographics
NPI:1356497168
Name:WALRATH, BENJAMIN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:WALRATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 CORTE CALYPSO
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-4433
Mailing Address - Country:US
Mailing Address - Phone:312-371-2612
Mailing Address - Fax:
Practice Address - Street 1:449 CORTE CALYPSO
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4433
Practice Address - Country:US
Practice Address - Phone:312-371-2612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241798207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services