Basic Information
| Provider Information | |||||||||
| NPI: | 1265584924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENTON | ||||||||
| FirstName: | CALVIN | ||||||||
| MiddleName: | BOYD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3669 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954023669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075354330 | ||||||||
| FaxNumber: | 7075354311 | ||||||||
| Practice Location | |||||||||
| Address1: | 3031 TELEGRAPH AVE | ||||||||
| Address2: | SUITE 217 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109818222 | ||||||||
| FaxNumber: | 5105688848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 09/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | C34382 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00C343820 | 05 | CA | MEDICAID |