Provider Demographics
NPI:1073592507
Name:NORMAN, BENJAMIN R (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:R
Last Name:NORMAN
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 1:2535 E LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-3821
Mailing Address - Country:US
Mailing Address - Phone:316-687-9794
Mailing Address - Fax:316-689-6957
Practice Address - Street 1:2535 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-3821
Practice Address - Country:US
Practice Address - Phone:316-687-9794
Practice Address - Fax:316-689-6957
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0421469207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
103550OtherMEDICARE
103550OtherMEDICARE