Provider Demographics
NPI:1770515959
Name:STOCKTON, BENJAMIN R (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:R
Last Name:STOCKTON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 GRAND CENTRAL AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4366
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2530 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5411
Practice Address - Country:US
Practice Address - Phone:480-834-4188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427930208800000X
MI4301089581208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI105185131Medicaid
MI1693157308Medicaid
P00888237OtherRR MEDICARE#
P00888237OtherRR MEDICARE#
MI105185131Medicaid
P00443779Medicare PIN
MI0M95670004Medicare PIN