Provider Demographics
NPI:1619355765
Name:ROOT, BENJAMIN ZIMMERMAN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ZIMMERMAN
Last Name:ROOT
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 1:11525 OLDE CABIN RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11525 OLDE CABIN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7146
Practice Address - Country:US
Practice Address - Phone:314-279-9049
Practice Address - Fax:314-997-5086
Is Sole Proprietor?:No
Enumeration Date:2015-05-09
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
MO2021008458207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program