Provider Demographics
NPI:1669452801
Name:BENKLE, DAVID JAY (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JAY
Last Name:BENKLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 LINCOLN CTR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-2644
Mailing Address - Country:US
Mailing Address - Phone:209-951-2020
Mailing Address - Fax:
Practice Address - Street 1:715 LINCOLN CENTER
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-2644
Practice Address - Country:US
Practice Address - Phone:209-951-2020
Practice Address - Fax:209-477-8192
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2007-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7417T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10533Medicare UPIN