Provider Demographics
NPI:1053441063
Name:BENHAM, DIRK A (DC)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:A
Last Name:BENHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10425 OLD OLIVE STREET RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5940
Mailing Address - Country:US
Mailing Address - Phone:314-303-8168
Mailing Address - Fax:
Practice Address - Street 1:10425 OLD OLIVE STREET RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5940
Practice Address - Country:US
Practice Address - Phone:314-303-8168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000153522111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU80155Medicare UPIN