Provider Demographics
NPI:1174554364
Name:BENSON, PAUL ALAN (DO)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ALAN
Last Name:BENSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1964 11 MILE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3046
Mailing Address - Country:US
Mailing Address - Phone:248-544-9300
Mailing Address - Fax:248-544-1148
Practice Address - Street 1:1964 11 MILE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3046
Practice Address - Country:US
Practice Address - Phone:248-544-9300
Practice Address - Fax:248-544-1148
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007480207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11271806OtherCAQH PROVIDER ID #
MIG07355OtherBCN GROUP #
MIPB007480OtherSTATE LICENSE #
MIG07355OtherBCN GROUP #
MIPB007480OtherSTATE LICENSE #