Basic Information
| Provider Information | |||||||||
| NPI: | 1679908669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLINGAN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | VINCENT | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 W SOUTHERN AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852104903 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2050 N ALMA SCHOOL RD STE 14 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852242889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807861075 | ||||||||
| FaxNumber: | 4807860476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2013 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1753 | SC | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT-002157 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.