Healthcare Provider Details

I. General information

NPI: 1235463944
Provider Name (Legal Business Name): BEN C PALMER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S MARY AVE STE 4
NIPOMO CA
93444-7821
US

IV. Provider business mailing address

150 S MARY AVE STE 4
NIPOMO CA
93444-7821
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-1982
  • Fax: 805-929-5052
Mailing address:
  • Phone: 805-929-1982
  • Fax: 805-929-5052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number100188
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13794
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1235463944
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer
# 2
IdentifierFI860A
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerGROUP MEDICARE PTAN
# 3
Identifier1346539095
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerTYPE II (GROUP) NPI
# 4
Identifier1235463944
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerTYPE I (INDIVIDUAL) NPI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: