Basic Information
| Provider Information | |||||||||
| NPI: | 1639148950 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | ERIC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3807 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850145005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022586797 | ||||||||
| FaxNumber: | 6022581134 | ||||||||
| Practice Location | |||||||||
| Address1: | 3807 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850145005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022586797 | ||||||||
| FaxNumber: | 6022581134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 07/21/2011 | ||||||||
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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 | 2084P0804X | 2483 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 276114 | 05 | AZ | MEDICAID |