Healthcare Provider Details

I. General information

NPI: 1750677167
Provider Name (Legal Business Name): BENJAMIN RECORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3395 MICHELSON DR #1224
IRVINE CA
92612-4438
US

IV. Provider business mailing address

3395 MICHELSON DR #1224
IRVINE CA
92612-4438
US

V. Phone/Fax

Practice location:
  • Phone: 801-674-9686
  • Fax:
Mailing address:
  • Phone: 801-674-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number137054
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number137054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: