Healthcare Provider Details

I. General information

NPI: 1437902889
Provider Name (Legal Business Name): BENJAMIN MATTHEW PHELPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST DEPT 5000
JACKSONVILLE FL
32214-5000
US

IV. Provider business mailing address

2080 CHILD ST DEPT 5000
JACKSONVILLE FL
32214-5000
US

V. Phone/Fax

Practice location:
  • Phone: 571-577-7924
  • Fax:
Mailing address:
  • Phone: 904-542-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number40472
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101287188
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: