Healthcare Provider Details

I. General information

NPI: 1487763470
Provider Name (Legal Business Name): BENSON DAITZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 ELM ST NE
ALBUQUERQUE NM
87102-2500
US

IV. Provider business mailing address

PO BOX 25701
ALBUQUERQUE NM
87125-0701
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-4919
  • Fax: 505-727-4915
Mailing address:
  • Phone: 505-727-4919
  • Fax: 505-727-4915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number74-19
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: