Healthcare Provider Details

I. General information

NPI: 1356497168
Provider Name (Legal Business Name): BENJAMIN DAVID WALRATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 CORTE CALYPSO
CHULA VISTA CA
91914-4433
US

IV. Provider business mailing address

449 CORTE CALYPSO
CHULA VISTA CA
91914-4433
US

V. Phone/Fax

Practice location:
  • Phone: 312-371-2612
  • Fax:
Mailing address:
  • Phone: 312-371-2612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101241798
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number0101241798
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: