Healthcare Provider Details

I. General information

NPI: 1285255448
Provider Name (Legal Business Name): BENJAMIN WIBONELE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 27TH AVE SE
PUYALLUP WA
98374-1145
US

IV. Provider business mailing address

PO BOX 1205
PUYALLUP WA
98371-0231
US

V. Phone/Fax

Practice location:
  • Phone: 253-770-9000
  • Fax: 253-770-9712
Mailing address:
  • Phone: 253-770-9000
  • Fax: 253-770-9712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberMD61666933
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD61666933
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: