Healthcare Provider Details

I. General information

NPI: 1427554336
Provider Name (Legal Business Name): BENSON KU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2018
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EXECUTIVE PARK DR NE # 200
ATLANTA GA
30329-2206
US

IV. Provider business mailing address

12 EXECUTIVE PARK DR NE # 300
ATLANTA GA
30329-2206
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-5526
  • Fax:
Mailing address:
  • Phone: 404-778-5526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number83839
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: