Provider Demographics
NPI:1952140998
Name:ANTAR, BENJAMIN JOHN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOHN
Last Name:ANTAR
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 1:111 WADSWORTH AVE APT 10A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-6108
Mailing Address - Country:US
Mailing Address - Phone:917-251-4850
Mailing Address - Fax:
Practice Address - Street 1:1227 BROADWAY # SC2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4302
Practice Address - Country:US
Practice Address - Phone:646-973-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031958-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist