Basic Information
| Provider Information | |||||||||
| NPI: | 1083654263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13640 N PLAZA DEL RIO BLVD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238763800 | ||||||||
| FaxNumber: | 6238766965 | ||||||||
| Practice Location | |||||||||
| Address1: | 14416 W MEEKER BLVD STE 301 | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238323880 | ||||||||
| FaxNumber: | 6232852710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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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 | 208800000X | 19371 | AZ | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 079641 | 05 | AZ | MEDICAID |