Basic Information
| Provider Information | |||||||||
| NPI: | 1871526186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENEDICK | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E. 33RD STREET | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605147550 | ||||||||
| FaxNumber: | 2083676123 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E. 33RD STREET | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083676030 | ||||||||
| FaxNumber: | 2083676123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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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 | MR-0864 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60255737 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 807490400 | 05 | ID | MEDICAID |