Provider Demographics
NPI:1235144924
Name:BENEDUM, JOHN LOYLE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LOYLE
Last Name:BENEDUM
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4369
Practice Address - Country:US
Practice Address - Phone:704-512-2506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20376207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1235144924Medicaid
NC110214041OtherMEDICARE- RR
SC346016Medicaid
NC8914850Medicaid
NC02682OtherBCBSNC
NC8914850Medicaid
NCNC5283BMedicare PIN
NC02682OtherBCBSNC
NCC87203Medicare UPIN
NC110214041OtherMEDICARE- RR
SC346016Medicaid