Provider Demographics
NPI:1780352468
Name:WARREN, BENJAMIN PHILIP
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:PHILIP
Last Name:WARREN
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 1:401 SW 4TH AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-1030
Mailing Address - Country:US
Mailing Address - Phone:312-865-9398
Mailing Address - Fax:
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:800-541-6682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2022-08-30
Deactivation Date:2022-05-09
Deactivation Code:
Reactivation Date:2022-08-30
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program