Provider Demographics
NPI:1669562815
Name:BENS, THEODORE (DPM)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:BENS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9224 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3832
Mailing Address - Country:US
Mailing Address - Phone:734-284-7600
Mailing Address - Fax:313-292-8430
Practice Address - Street 1:9224 PELHAM RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3832
Practice Address - Country:US
Practice Address - Phone:734-284-7600
Practice Address - Fax:313-292-8430
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001481213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2649282Medicaid
MI4858255590OtherBCBSM
MI4858255590OtherBCBSM