1821306648 NPI number — BENTON ASHLOCK MD

Table of content: BENTON ASHLOCK MD (NPI 1821306648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821306648 NPI number — BENTON ASHLOCK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ASHLOCK
Provider First Name:
BENTON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ASHLOCK
Provider Other First Name:
BENTON
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1821306648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 62106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA BARBARA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93160-2106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-898-3400
Provider Business Mailing Address Fax Number:
805-898-3420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W PUEBLO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA BARBARA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93105-4310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-898-3400
Provider Business Practice Location Address Fax Number:
805-898-3420
Provider Enumeration Date:
09/14/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X , with the licence number:  A118255 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: A118255 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A118255 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".