Healthcare Provider Details

I. General information

NPI: 1528039799
Provider Name (Legal Business Name): RIPUDAMAN S BENIWAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 NORMAN DR STE 101 1530 N BESSIE AVE, STE104, TRACY CA 95376 ( 2ND OFFICE)
MANTECA CA
95336-5959
US

IV. Provider business mailing address

1144 NORMAN DR STE 101
MANTECA CA
95336-5959
US

V. Phone/Fax

Practice location:
  • Phone: 209-239-0515
  • Fax: 209-239-0504
Mailing address:
  • Phone: 209-835-2992
  • Fax: 209-835-3296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA67409
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: