Healthcare Provider Details

I. General information

NPI: 1558467118
Provider Name (Legal Business Name): BENJAMIN BENSOUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981 MANOR WAY
SAN DIEGO CA
92106-2035
US

IV. Provider business mailing address

981 MANOR WAY
SAN DIEGO CA
92106-2035
US

V. Phone/Fax

Practice location:
  • Phone: 619-368-8734
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberG51352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: