Basic Information
| Provider Information | |||||||||
| NPI: | 1033142526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENCH | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1554 | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117900988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314440650 | ||||||||
| FaxNumber: | 6316384170 | ||||||||
| Practice Location | |||||||||
| Address1: | HSC T16 080 | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117948167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314441060 | ||||||||
| FaxNumber: | 6314441054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 00245267 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 245267 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 245267 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 363A00000X | 006594 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 390200000X | 245267 | NY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 03424935 | 05 | NY | MEDICAID | 245267 | 01 | NY | NYS LICENSE | OTHER |