Basic Information
| Provider Information | |||||||||
| NPI: | 1578639779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2710 SAINT FRANCIS DR | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192725000 | ||||||||
| FaxNumber: | 3192728059 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 SAINT FRANCIS DR | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192725000 | ||||||||
| FaxNumber: | 3192728059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 11/08/2016 | ||||||||
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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 | 207Q00000X | 4295 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1578639779 | 05 | IA | MEDICAID |