Provider Demographics
NPI:1023209624
Name:MARINO, BENTON ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BENTON
Middle Name:ROBERT
Last Name:MARINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6517 SPANISH FORT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW OLREANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-2429
Mailing Address - Country:US
Mailing Address - Phone:504-283-7306
Mailing Address - Fax:
Practice Address - Street 1:6517 SPANISH FORT BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70124-4321
Practice Address - Country:US
Practice Address - Phone:504-283-7306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.205530208000000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04484201Medicaid
LA2313444Medicaid
TXTXB110014Medicare PIN
MS04484201Medicaid