Basic Information
| Provider Information | |||||||||
| NPI: | 1174866040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DA | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | LIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 400 COMMUNITY DR | ||||||||
| Address2: | |||||||||
| City: | MANHASSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110303815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165624664 | ||||||||
| FaxNumber: | 5165622683 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 COMMUNITY DR | ||||||||
| Address2: | |||||||||
| City: | MANHASSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110303815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165624664 | ||||||||
| FaxNumber: | 3232262657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2013 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 304341 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RI0008X | 304341 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology |
ID Information
| ID | Type | State | Issuer | Description | BD3232267556 | 01 | CA | BD3232267556 | OTHER |