Healthcare Provider Details

I. General information

NPI: 1336212281
Provider Name (Legal Business Name): BENJAMIN BRENT M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 STANIFORD ST 2ND FLOOR
BOSTON MA
02114-2503
US

IV. Provider business mailing address

25 STANIFORD ST 2ND FLOOR
BOSTON MA
02114-2503
US

V. Phone/Fax

Practice location:
  • Phone: 617-912-7800
  • Fax: 617-723-3919
Mailing address:
  • Phone: 617-912-7800
  • Fax: 617-723-3919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberBB5078654BB223PY
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: