Healthcare Provider Details

I. General information

NPI: 1366753204
Provider Name (Legal Business Name): JEREMY EVAN BENJAMINSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5831 BEE RIDGE RD STE 210
SARASOTA FL
34233-5094
US

IV. Provider business mailing address

PO BOX 25487
SARASOTA FL
34277-2487
US

V. Phone/Fax

Practice location:
  • Phone: 941-379-8481
  • Fax: 941-379-3781
Mailing address:
  • Phone: 941-202-5342
  • Fax: 855-253-4836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102202899
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102202899
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS14077
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: