MEDICARE: DR. JESSIKA BENJAMIN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT33415TLG	CA

General Provider Information

NPI Number	:	1568815611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSIKA BENJAMIN O.D.

Provider Business Mailing Address
First Line	:	9337 MONTE VISTA AVE
Second Line	:
City	:	MONTCLAIR
State	:	CA
Zip	:	91763-1924
Country	:	US
Telephone Number	:	909-624-6809
Fax Number	:	909-624-7487

Provider Business Practice Location Address
First Line	:	471 N CENTRAL AVE
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91786-4219
Country	:	US
Telephone Number	:	909-788-3433
Fax Number	:	909-624-7487

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2016
Last Update Date	:	07/19/2023

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