Provider Demographics
NPI:1770764938
Name:KENNETH J. BENJAMIN, DPM, PA
Entity type:Organization
Organization Name:KENNETH J. BENJAMIN, DPM, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-695-9669
Mailing Address - Street 1:198 THOMAS JOHNSON DRIVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702
Mailing Address - Country:US
Mailing Address - Phone:301-695-9669
Mailing Address - Fax:301-695-0346
Practice Address - Street 1:198 THOMAS JOHNSON DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4448
Practice Address - Country:US
Practice Address - Phone:301-695-9669
Practice Address - Fax:301-695-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00592213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT30909Medicare UPIN
MD620LN070Medicare UPIN
MD0468530002Medicare NSC
MDK374Medicare PIN