Provider Demographics
NPI:1831253368
Name:DY, BENJAMIN O (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:O
Last Name:DY
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 1:7116 153RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-4297
Mailing Address - Country:US
Mailing Address - Phone:206-619-4965
Mailing Address - Fax:
Practice Address - Street 1:4314 E PORTLAND AVE STE 7
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-4696
Practice Address - Country:US
Practice Address - Phone:253-476-9121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF76479Medicare UPIN