Provider Demographics
NPI:1780737262
Name:BENJAMIN, EDWARD HARRIS (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:HARRIS
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ELM ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3712
Mailing Address - Country:US
Mailing Address - Phone:860-741-2531
Mailing Address - Fax:860-745-7587
Practice Address - Street 1:115 ELM ST
Practice Address - Street 2:SUITE 205
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3712
Practice Address - Country:US
Practice Address - Phone:860-741-2531
Practice Address - Fax:860-745-7587
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT021127207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0044560OtherAETNA
061044668 0001OtherCIGNA
CT1211275Medicaid
052513OtherCONNECTICARE
P857762OtherOXFORD
010021127CT01OtherBLUE CROSS
0000P00382OtherHEALTH NET
070000107Medicare ID - Type Unspecified
061044668 0001OtherCIGNA