Healthcare Provider Details

I. General information

NPI: 1508495201
Provider Name (Legal Business Name): BENJAMIN MICHAEL TAYLOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL CENTER SAN DIEGO PSYCHIATRY RESIDENCY PGM 34800 BOB WILSON DRIVE
SAN DIEGO CA
92134
US

IV. Provider business mailing address

34800 BOB WILSON DRIVE PSYCHIATRY DEPT
SAN DIEGO CA
92134-2370
US

V. Phone/Fax

Practice location:
  • Phone: 619-301-9892
  • Fax:
Mailing address:
  • Phone: 619-532-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: