Healthcare Provider Details

I. General information

NPI: 1063467595
Provider Name (Legal Business Name): JACOB BENFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 NORTH JACKSON AVENUE
SAN JOSE CA
95116
US

IV. Provider business mailing address

2100 POWELL STREET SUITE 900
EMERYVILLE CA
94608-1804
US

V. Phone/Fax

Practice location:
  • Phone: 408-923-7121
  • Fax:
Mailing address:
  • Phone: 510-350-2664
  • Fax: 510-879-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD195812
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA60475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: