Provider Demographics
NPI:1053438242
Name:BENNOF, BOAZ I (PT)
Entity type:Individual
Prefix:
First Name:BOAZ
Middle Name:I
Last Name:BENNOF
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 DAMASCUS CT
Mailing Address - Street 2:APT. E
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3030
Mailing Address - Country:US
Mailing Address - Phone:410-318-8623
Mailing Address - Fax:
Practice Address - Street 1:2812 DAMASCUS CT
Practice Address - Street 2:APT. E
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3030
Practice Address - Country:US
Practice Address - Phone:410-318-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist