Healthcare Provider Details

I. General information

NPI: 1790975647
Provider Name (Legal Business Name): BENJAMIN USLEMAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 E SOUTHERN AVE #2410
MESA AZ
85206-3718
US

IV. Provider business mailing address

11103 WEST AVE STE 6
SAN ANTONIO TX
78213-1370
US

V. Phone/Fax

Practice location:
  • Phone: 480-854-3468
  • Fax: 480-985-7346
Mailing address:
  • Phone: 210-524-6803
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1579
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: