Provider Demographics
NPI:1487445896
Name:BENJAMIN, LAUREL R
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:R
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9237 REGENTS RD UNIT K117
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9186
Mailing Address - Country:US
Mailing Address - Phone:909-247-9775
Mailing Address - Fax:
Practice Address - Street 1:3665 KEARNY VILLA RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1954
Practice Address - Country:US
Practice Address - Phone:858-966-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program