Healthcare Provider Details

I. General information

NPI: 1760003743
Provider Name (Legal Business Name): BENJAMIN TAYLOR MAUTNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0816
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-1931
  • Fax: 434-243-5770
Mailing address:
  • Phone: 434-924-1931
  • Fax: 434-243-5770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101281409
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: