Provider Demographics
NPI:1447282702
Name:TELLER, BENJAMIN M (OD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:TELLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 N PARK AVE
Mailing Address - Street 2:PLAZA NORTH
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-4518
Mailing Address - Country:US
Mailing Address - Phone:301-841-6776
Mailing Address - Fax:301-215-4144
Practice Address - Street 1:4600 NORTH PARK AVENUE
Practice Address - Street 2:PLAZA NORTH
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815
Practice Address - Country:US
Practice Address - Phone:301-841-6776
Practice Address - Fax:301-215-4144
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1389152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD375649Medicare PIN
U88428Medicare UPIN