Provider Demographics
NPI:1043307739
Name:BENTON, MINDY L (DPM)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:L
Last Name:BENTON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVENUE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:651-642-9441
Practice Address - Street 1:1020 BANDANA BLVD W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5107
Practice Address - Country:US
Practice Address - Phone:651-641-7000
Practice Address - Fax:651-641-7166
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN515213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN533718600Medicaid
MN533718600Medicaid