Provider Demographics
NPI:1306867106
Name:BENSON, MARY J (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:BENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 N E ST
Mailing Address - Street 2:STE 205
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-6336
Mailing Address - Country:US
Mailing Address - Phone:850-434-1863
Mailing Address - Fax:850-432-9090
Practice Address - Street 1:1717 N E ST
Practice Address - Street 2:STE 205
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6336
Practice Address - Country:US
Practice Address - Phone:850-434-1863
Practice Address - Fax:850-432-9090
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58043208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064663600Medicaid
FL100003795OtherRRB PTAN
FL064663600Medicaid
FL11545Medicare PIN