Healthcare Provider Details

I. General information

NPI: 1871390575
Provider Name (Legal Business Name): MATTHEW BENJAMIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 COTNER AVE
LOS ANGELES CA
90025-3303
US

IV. Provider business mailing address

502 FAIRLAWN AVE
TORONTO ONTARIO
M5M1V2
CA

V. Phone/Fax

Practice location:
  • Phone: 310-445-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number172309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: