Basic Information
| Provider Information | |||||||||
| NPI: | 1063598548 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENEDICT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 DRY CREEK DR | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805036499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037723300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 DRY CREEK DR | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805036505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037723300 | ||||||||
| FaxNumber: | 3036823380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 32437 | CO | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 32437 | CO | Y |
ID Information
| ID | Type | State | Issuer | Description | 01324375 | 05 | CO | MEDICAID |