1720154529 NPI number — JAIME C BENTON MD PA

Table of content: (NPI 1720154529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720154529 NPI number — JAIME C BENTON MD PA

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720154529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 E WASHINGTON
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAVASOTA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77868-3002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-825-6444
Provider Business Mailing Address Fax Number:
936-825-3340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 E WASHINGTON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAVASOTA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77868-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-825-6444
Provider Business Practice Location Address Fax Number:
936-825-3340
Provider Enumeration Date:
11/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENTON
Authorized Official First Name:
JAIME
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER PRIMARY CARE PHYSICIAN
Authorized Official Telephone Number:
936-825-6444

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  M0619 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M0619 . This is a "PHYSICIAN PERMIT" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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