Healthcare Provider Details

I. General information

NPI: 1689907859
Provider Name (Legal Business Name): BENJAMIN DOUGLAS KORMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 06/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 LATTIMORE RD STE G-110
ROCHESTER NY
14620-4159
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX MED
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-486-0901
  • Fax: 585-340-5399
Mailing address:
  • Phone: 585-784-9842
  • Fax: 585-427-8718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberAN52403949533
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number291476
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: