Provider Demographics
NPI:1164698932
Name:NETTLETON, BENJAMIN REED (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:REED
Last Name:NETTLETON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 CENTURY MEDICAL DR
Mailing Address - Street 2:CREDENTIALING OFFICE
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2100
Mailing Address - Country:US
Mailing Address - Phone:321-268-6264
Mailing Address - Fax:321-268-6273
Practice Address - Street 1:5005 PORT ST JOHN PKWY
Practice Address - Street 2:SUITE 2500
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-4305
Practice Address - Country:US
Practice Address - Phone:321-504-0556
Practice Address - Fax:321-504-0773
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT011289207Q00000X
WAOP0077518207Q00000X
FLOS13715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA249449OtherLABOR & INDUSTRIES
WA8544645Medicaid
FL019231000Medicaid
WA249449OtherLABOR & INDUSTRIES
WA8544645Medicaid