Provider Demographics
NPI:1073670154
Name:BENFORD, DONNA SMITH (DO)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:SMITH
Last Name:BENFORD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 TORREY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3327
Mailing Address - Country:US
Mailing Address - Phone:810-714-7369
Mailing Address - Fax:810-714-9258
Practice Address - Street 1:1100 TORREY RD STE 300
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3327
Practice Address - Country:US
Practice Address - Phone:810-714-7369
Practice Address - Fax:810-714-9258
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4721123Medicaid
MI4721123Medicaid
MI0P12000Medicare ID - Type Unspecified