Healthcare Provider Details

I. General information

NPI: 1649241886
Provider Name (Legal Business Name): JON W BENNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 UPPER RAGSDALE DR B230
MONTEREY CA
93940-5736
US

IV. Provider business mailing address

2 UPPER RAGSDALE DR STE B230
MONTEREY CA
93940-7853
US

V. Phone/Fax

Practice location:
  • Phone: 831-649-1000
  • Fax:
Mailing address:
  • Phone: 831-649-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG41631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: