Basic Information
| Provider Information | |||||||||
| NPI: | 1750817367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESTERHAUS | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 901 45TH ST | ||||||||
| Address2: | |||||||||
| City: | MANGONIA PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618445255 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 45TH ST | ||||||||
| Address2: | |||||||||
| City: | MANGONIA PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545671332 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2017 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/13/2018 | ||||||||
| NPIReactivationDate: | 08/29/2018 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 04-43471 | KS | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | ME149026 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | ME149026 | 01 | FL | FLORIDA MEDICAL LICENSE | OTHER |