Healthcare Provider Details

I. General information

NPI: 1073833497
Provider Name (Legal Business Name): BENJAMIN C SERVICE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 S ORANGE AVE
ORLANDO FL
32806-1215
US

IV. Provider business mailing address

7243 DELLA DR STE B
ORLANDO FL
32819-5106
US

V. Phone/Fax

Practice location:
  • Phone: 407-423-7777
  • Fax: 407-423-1380
Mailing address:
  • Phone: 321-842-0060
  • Fax: 321-842-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD60545556
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME 124973
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: