Provider Demographics
NPI:1750570594
Name:BENJAMIN, RICHARD W
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 W 116 ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-2450
Mailing Address - Country:US
Mailing Address - Phone:212-666-3620
Mailing Address - Fax:212-666-3985
Practice Address - Street 1:248 W 116 ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-2450
Practice Address - Country:US
Practice Address - Phone:212-666-3620
Practice Address - Fax:212-666-3985
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004372156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00997613Medicaid